Republic of Kenya

Ministry of Health

A report on the Performance Status

2003 and 2004

Health Management Information System A report on the Performance Status

Health Management Information System

2003 – 2004 annual report

This document may be freely copied on the understanding that full acknowledgement is made to the Ministry of Health; Health Management Information Systems. Contents

ABBREVIATIONS...... VIII FORWARD...... IX ACKNOWLEDGEMENTS:...... XI EXECUTIVE SUMMARY...... I 1. CHAPTER 1 – COUNTRY PROFILE...... 1

1.1 Introduction...... 1 1.1.1 Location and Administrative units ...... 1 1.1.2 Political Organisation...... 1 1.1.3 Topology and geology...... 1 1.1.4 Climate ...... 2

1.2 Trends in Socio-economic development ...... 2 1.2.1 Economic Trends...... 2 1.2.2 Demographic features ...... 2

1.3 Trends in Health Status Indicators...... 5 1.3.1 Childhood Mortality...... 6 1.3.2 Maternal Mortality ...... 7 1.3.3 Fertility levels ...... 7 1.3.4 Current contraceptive use ...... 8 1.3.5 Delivery in health facilities...... 9 1.3.6 Social determinants of health...... 9 1.3.6.1 Education and literacy rates...... 9 1.3.6.2 Unemployment ...... 10 1.3.6.3 Poverty...... 11 1.3.7 Development indices...... 11 2. `PUBLIC SECTOR HEALTH CARE FINANCING AND EXPENDITURE...... 12

2.1 Financing...... 12 2.1.1 Expenditure...... 12 2.1.2 Ministry of Health Expenditure by sub Vote...... 13 2.1.3 Ministry of Health Recurrent Expenditure by Economic Category...... 15 2.1.4 Health services...... 16

2.2 Financial Performance of Cost Sharing Programme...... 19 2.2.1 Reporting Rates ...... 19 2.2.2 Trends in cost sharing revenues ...... 19

2.3 National Health Insurance Fund Income & Expenditure Analysis ...... 20 2.3.1 Benefits ...... 21 2.3.2 Personnel...... 21 2.3.3 Operations and Maintenance ...... 21 2.3.4 Surplus...... 21 3. DIVISION OF HEALTH CARE FINANCE ...... 24

3.1 Financial Performance of the Cost Sharing Programme ...... 24 3.1.1 Reporting rates...... 24 3.1.2 Revenue...... 24 3.1.2.1 Revenue Banking ...... 25 3.1.3 Expenditure...... 26 3.1.4 Waivers and exemptions ...... 27

3.2 National Hospital Insurance Fund Claims ...... 27 3.2.1 Manuals Developed...... 28 3.2.2 Resources ...... 28 3.2.3 Way forward for division of health care financing ...... 28 4. PREVENTIVE AND PROMOTIVE SERVICES...... 29 i Annual Report 2003 - 2004 4.1 Nutrition and Growth Monitoring Services ...... 29 4.1.1 Growth Monitoring and Promotion...... 29

4.2 Child Health Services ...... 37 4.2.1 Aims of the Division of Child Health ...... 38

4.3 Malaria Control Programme ...... 41 4.3.1 Introduction...... 41 4.3.2 Trainings ...... 42 4.3.3 Management of malaria and anaemia in pregnancy...... 42 4.3.4 Vector control using insecticide- treated nets and other methods...... 43 4.3.5 Epidemic preparedness and response...... 43 4.3.6 Information, Education and Communication ...... 45 4.3.7 Monitoring, Evaluation and Research...... 46 4.3.8 Malaria surveillance ...... 46

4.4 Disease Outbreak Management Unit (Domu)...... 57 4.4.1 Communicable diseases reported in 2002, 2003 and 2004...... 57 4.4.2 Reported outbreks and responses given...... 59

4.5 HIV/AIDS – NASCOP Services ...... 60 4.5.1 Sentinel surveillance ...... 60 4.5.2 Trained ARV officers...... 69 4.5.3 Blood safety...... 74 4.5.4 Home based care...... 76

4.6 Expanded programme on immunizations (EPI) services ...... 77 4.6.1 Disease surveillance activities ...... 93 4.6.1.1 Acute flaccid paralysis (AFP) ...... 93 4.6.1.2 Measles Surveillance...... 94 4.6.1.3 Maternal And Neonatal Tetanus Surveillance...... 95 4.6.2 Cold chain services...... 96 4.6.2.1...... 100 4.6.3 Cold chain maintenance activities...... 103 5. REPRODUCTIVE HEALTH (RH) SERVICES...... 104 6. DIVISION OF ENVIRONMENTAL HEALTH ...... 105 6.1.1 Staff establishment and transport services...... 105 6.1.2 Food Quality Control Services ...... 107 6.1.3 Waste Management ...... 109 6.1.4 Law Enforcement ...... 109 7. CURATIVE AND REHABILITATIVE HEALTH SERVICES ...... 111 7.1.1 Orthopaedic technology services...... 111 7.1.2 Physiotherapy services...... 112 7.1.3 Community Based Rehabilitation (Cbr) ...... 113 8. DIVISION OF OPHTHALMIC SERVICES...... 119 9. MENTAL HEALTH SERVICES ...... 123 9.1.1 Introduction...... 123 9.1.2 Mental health care services...... 126 10. PUBLIC INSTITUTIONS...... 131

10.1 KNH inputs to the annual health performance report 2003 and 2004...... 131 10.1.1 Renal Unit ...... 134 10.1.2 Personnel ...... 140 10.1.3 Annual Collections, Expenditures, Allocation 2002, 2003 And 2004 ...... 144 10.1.4 Resources Available ...... 145

10.2 Moi Teaching and Referral Hospital ...... 147 10.2.1 Moi teaching referral hospital specialised services ...... 148

10.3 Mathari Mental Hospital...... 150 ii Annual Report 2003 - 2004 11. LABORATORY SERVICES...... 152

11.1 Bacteriological Analysis ...... 152

11.2 Cholera organisms isolated by region...... 153

11.3 Drug Effectiveness ...... 155

11.4 Tuberculosis and haemogram levels by district 2002 – 2004...... 158 12. NATIONAL TRENDS OF OUTPATIENT MORBIDITY...... 170 13. HOSPITAL ADMINISTRATIVE STATISTICS...... 200 14. HUMAN RESOURCE MAPPING ...... 210

14.1 Staffing Level by Designation and Gender...... 210

14.2 Skill mix in Health Facilities ...... 213

14.3 Distribution of Key Health Personnel by Province ...... 217

14.4 Staffing Norms...... 218

14.5 Distribution of Key Personnel by Age...... 219

14.6 Academic Qualification and Training ...... 219

iii Annual Report 2003 - 2004 LIST OF TABLES

Table 1: Kenya - Summary of age structure (2004)...... 3 Table 2: Social-demographic characteristics, Kenya ...... 4 Table 3: Trends and differentials in Infant and Under-five Mortality rates (per 1000 live births)...... 6 Table 4: Trends in Maternal Mortality...... 7 Table 5: Trends in Total Fertility Rates by Residence and Province...... 8 Table 6: Trends in current contraceptive use...... 8 Table 7: Percentage Distribution of Births delivered in Health Facility ...... 9 Table 9: Unemployment Rates for population ...... 10 Table 10: Differentials overall absolute poverty by adult equivalent ...... 11 Table 11 : Development indices ...... 11 Table 12: Ministry of Health Expenditures (Gross) KSh million ...... 13 Table 13: Ministry of Health Actual Recurrent & Development Expenditures...... 14 Table 14: Recurrent (gross) Expenditure by Economic Category KSh millions ...... 16 Table 15: General NHA Summary Statistics (2001/2002) ...... 18 Table 16: Reporting rates by facility type and by province...... 19 Table 17: Total reported revenue collections by province and financial year...... 20 Table 18: NHIF Income and Expenditure...... 22 Table 19: Expenditures as % of contributions...... 22 Table 20: Facility reporting rates by province – FYs 1999/00 to 2002/03...... 24 Table 21: Cash revenues by province – FYs 1999/00 to 2002/03...... 25 Table 22: KNH and MTRH revenues – FY 1999/00 to 2002/03 ...... 25 Table 23: Cost sharing collections vs. banking – FYs 2000/01 to 2002/03 ...... 26 Table 24: Waivers and exemptions by facility type (percentages) – FY 2002/03 ...... 27 Table 25: NHIF reimbursements in cost sharing resources (KES millions)...... 27 Table 26: Trainings Carried Out...... 28 Table 27: Percentage of children underweight per district from 2002 to 2004...... 29 Table 28: Percent of children with stunted growth from 2002 to 2004 ...... 31 Table 29: Malnutrition cases by district from 2002 to 2004 ...... 34 Table 30: Resources Available...... 37 Table 31: Districts implementing IMCI by province ...... 38 Table 32: Number of clinical health workers trained (accumulated totals)...... 38 Table 33: IMCI activity matrix...... 39 Table 34: Shopkeeper (IMCI)...... 42 Table 35: Focused Antenatal Care and Malaria in Pregnancy (FANC/MIP)...... 43 Table 36: Distribution of ITNS and IRS Materials ...... 43 Table 37: Makueni district malaria data ...... 44 Table 38: Summary of IEC materials distributed in 2003 ...... 45 Table 39: Malaria Sentinel crude data reported by districts in the year 2003 ...... 47 Table 40: Summary of Sentinel Surveillance Data by district ...... 50 Table 41: Summary of malaria cases in 6 reporting districts ...... 52 Table 42: Outcome of a malaria drug efficancy...... 53 Table 43: Disease Outbreaks Reported...... 58 Table 44: Cholera Trends 1979 - 2004 ...... 58 Table 45: Sample size sentinel sites...... 60 Table 46: Number of women recruited into the exercise...... 61 Table 47: HIV Prevalence (%) Rates Of Women In The Sentinel Sites 1990 - 2003...... 62 Table 48: Information For Std Patients That Attended Sentinel Clincs In 2003...... 66 Table 50: National Vct Uptake by gender ...... 69 Table 51: National estimates 2003 hiv/aids...... 72 Table 52: Prevention Mother To Child Transmission Of Hiv/Aids (Pmtct) 2004...... 75 Table 53: PMTCT uptake maternity unit 2004 ...... 76 Table 54: Epi Specific Coverages, Accessibility And Utilization By Province 2004 ...... 80 Table 55: Epi Specific Coverages, Accessibility And Utilization By Province 2003 ...... 80 Table 56: Summary coverage for antigens (<1y) by district 1/2004 to 12/2004...... 82 Table 57: EPI coverages by district 2003 ...... 85 Table 58: Immunization Coverage 2002 Report On Infant Antigens ...... 88 Table 59: Results of Acute Flaccid Paralysis (AFP) indicators for 1996 – 2004...... 93 Table 60: showing measles IgM positive cases 2003 and 2004...... 94 Table 61: Maternal and neonatal tetanus elimination supplemental ...... 95 Table 62: MF 314 Freezers...... 96 Table 63: RCW 50 EG...... 97 Table 64: Allocation of gas. cylinder unicef support to cold chain (epi-kenya october 2003)...... 97 Table 65: GOK Procurement in 2003 ...... 99 Table 66: Spare Parts Procured By Gavi Funds ...... 100 Table 67: Family Planning commodities distributed from KEMSA/FP Section in 2000- 2004...... 104 Table 68:Potential CYPs according to distribution...... 104 Table 69 : Public Health Personnel by Province 2003...... 105 Table 70: Motor Vehicles and Motor Bikes by district 2003 ...... 105 Table 71: Food Sampling...... 108 Table 72: Medical Examination of food Handlers ...... 108 Table 73: Property Inspection...... 108 Table 74: Approval of Building Plans ...... 108 Table 75: Water quality Control...... 108 Table 76: Number of patients and appliances given 2003 / 2004 by clinic/province...... 111 Table 77: Clinical (curative) physiotherapy services...... 112 Table 78: Identified PWDs from 16 districts...... 115 Table 79: Community own resource persons ...... 116 Table 80: Refered Cases ...... 116 Table 81: Cases identified and interventions taken by province...... 117 Table 82: Summary data for the years 2000-2004...... 120 Table 83: Ophthalmic programme progres...... 122 Table 84: Personnel requirement...... 128 Table 85: Radiotherapy Procedures - 2003...... 132 Table 86: Radiotherapy Procedures - 2004...... 133 Table 87: Renal Unit Procedures - 2003...... 135 Table 88: Renal Unit Procedures - 2004...... 136 Table 89: Cardiac and EEG procedures 2000 - 2004...... 136 Table 90: Cardiac procedures 2003...... 137 Table 91: Cardiac procedures 2004...... 137 Table 92: Leading Causes of Out-Patient Attendance ...... 138 Table 93: Top Ten Leading Causes Of Hospitalization 2002 ...... 139 Table 94: Top Ten Leading Causes of Hospitalization 2003 ...... 139 Table 95:Top Ten In-Patient Mortality For 2002 And 2003 ...... 140 Table 96: Summary of Approved Posts and Inposts...... 141 Table 97: KENYATTA NATIONAL HOSPITAL administrative statistics 2000-2004...... 144 Table 98: Vehicles as per Classifications ...... 145 Table 99: Top ten causes of outpatient morbidity mtrh 2002 – 2004 ...... 147 Table 100: Top ten causes of in-patient morbidity mtrh 2002 – 2004...... 147 Table 101: Top ten causes of in-patient mortality moi teaching and referral hospital 2002 – 2004...... 148 Table 102: MTRH specialised services 2000 – 2004...... 148 Table 103: Hospital administrative statistics 2002 – 2004...... 148 Table 104: Annual allocations, collections and expenditures mtrh 2002 – 2004...... 148 Table 105: Current Vehicles in MTRH...... 149 Table 106: Current Personnel in MTRH...... 149

v Annual Report 2003 - 2004 Table 107: Causes of mental ill health/ Hospitalized in Mathari Mental hospital 2003...... 151 Table 108: Age Distribution of Cholera Cases By District ...... 154 Table 109: Drug effectiveness...... 155 Table 110: Malarial Investigations...... 156 Table 111: TB and HB investigations...... 158 Table 112: Immun0 haematology investigations 2002 - 2004 ...... 160 Table 113: Serological investigations 2002 - 2004 ...... 164 Table 114: Parasitology and haematological investigations 2002 - 2004...... 166 Table 115: Top Ten Causes of Morbidity 2004 by Province ...... 172 Table 116: Top Ten Causes of Outpatient Morbidity 2003 by Province...... 172 Table 117: Out-patient morbidity provincial summary year 2004...... 174 Table 118: Out Patient morbidity district summary year 2003 (Central Province) ...... 175 Table 119: Out Patient morbidity district summary year 2004 (Central Province) ...... 177 Table 120: Out Patient morbidity district summary year 2003 (Western Province)...... 178 Table 121: Out Patient morbidity district summary year 2004 (Western Province)...... 179 Table 122: Out Patient morbidity district summary year 2003 (Coast Province) ...... 180 Table 123: Out Patient morbidity district summary year 2004 (Coast Province) ...... 181 Table 124: Out Patient morbidity district summary year 2003 (North Eastern Province) ...... 182 Table 125: Out Patient morbidity district summary year 2004 (North Eastern) ...... 183 Table 126: Out Patient morbidity district summary year 2003 and 2004 (Nairobi Province) ...... 184 Table 127: Out Patient morbidity district summary year 2003 (Nyanza Province)...... 186 Table 128: Out Patient morbidity district summary year 2004 (Nyanza Province)...... 187 Table 129: Out Patient morbidity district summary year 2003 (Eastern Province) ...... 189 Table 130: Out Patient morbidity district summary year 2004 (Eastern Province) ...... 191 Table 131: Out Patient morbidity district summary year 2003 (Rift Valley Province) ...... 193 Table 132: Out Patient morbidity district summary year 2004 (Rift Valley Province) ...... 196 Table 133: National Summary Hospital Administriatve Statistics 2004...... 201 Table 134: Central Province Administriatve Statistics 2004...... 201 Table 135: Nairobi Province Hospital Administriatve Statistics 2004 ...... 202 Table 136: North Eastern Province Hospital Administriatve Statistics 2004...... 203 Table 137: Eastern Province Administriatve Statistics 2004 ...... 203 Table 138: Nyanza Hospital Administriatve Statistics 2004...... 204 Table 139: Coast Province Hospital Administriatve Statistics 2004 ...... 205 Table 140:Rift Valley Province Hospital Administriatve Statistics 2004 ...... 206 Table 141: Facility Utilization for Provincial and District Hospitals ...... 207 Table 142: Number of Beds by Province...... 209 Table 143: Workforce Profile by Gender and Facility Type...... 210 Table 144: Distribution of Key Health Personnel by Designation and Gender ...... 213 Table 145: Employee Distribution by Designation and Gender ...... 215 Table 146: Distribution of Key Health Personnel by Province...... 217 Table 147: Distribution of Dispensaries Understaffed by Staff Category...... 218 Table 148: Distribution of Key Health Personnel by Age-Group...... 219 Table 149: Distribution of Employees by Academic Qualifications ...... 219 Table 150: Employee Distribution of Last Training Date ...... 220

vi Annual Report 2003 - 2004 LIST OF FIGURES

Figure 1: Administrative Map ...... 1 Figure 2: Vital rates...... 5 Figure 3 Infant and Under 5 Mortality Rates (KDHS 2003) by Wealth Quintiles ...... 7 Figure 4: Trends in Recurrent and Development Expenditures...... 13 Figure 5 Percent Distribution of MoH Spending by Economic Inputs 2003/04 ...... 16 Figure 6 the Kenya Health Shilling 2001/02 – Where It Came From ...... 17 Figure 7: Contributions ...... 21 Figure 8: NHIF Income & Expenditure Analysis...... 23 Figure 9: NHIF Income & expenditure Analysis ...... 23 Figure 10: National expenditure of cost sharing resources – FY 2002/03 ...... 26 Figure 11: Malnutrition Cases ...... 36 Figure 12: Malnutrition rate by province 2004 ...... 36 Figure 13: Makueni District Malaria Threshold...... 44 Figure 14: Malaria trends for the year 2003 in 14 districts ...... 48 Figure 15: Malaria trends in 5 epidemic prone districts in 2003...... 48 Figure 16: Malaria trends in 10 districts in 2003 ...... 49 Figure 17: Number of Malaria cases by age in 5 epidemic prone districts...... 52 Figure 18: Estimated percentage of sick population in 5 sentinel districts ...... 52 Figure 19: Cholera Outbreak in Kwale, 2002...... 58 Figure 20: Reported Cases of Cholera 1979 - 2004...... 59 Figure 21: Distribution of Women by age group...... 61 Figure 22: Sites that declined in the last 2 years...... 64 Figure 23: Sites with Constant HIV prevalence in 2002 and 2003...... 64 Figure 24:Sites with increasing prevalence in 2002 and 2003...... 64 Figure 25: Sites with Over 20% Prevalence ...... 64 Figure 26: sites with prevalence between 10 and 20 percent in 2003...... 64 Figure 27: Sites with <10% Prevalence ...... 65 Figure 28: Trend of HIV among pregnant women in selected Sentinel sites...... 65 Figure 30: Trend of the national estimate of the HIV prevalence in Kenya since 1990...... 66 Figure 32: HIV prevalence among STD patients by age group ...... 68 Figure 33: HIV rates by std syndromes (2002/2003)...... 69 Figure 34: HIV prevalence between std and antenatal patients (1999-2003)...... 69 Figure 35: National vct uptake 2001 – 2004 ...... 70 Figure 36:National vct sero-prevalence 2001 - 2004...... 71 Figure 37: PMTCT uptake by province 2004...... 75 Figure 38 :National Epi Timeliness And Completeness Of Reports 2003 And 2004 By Province...... 78 Figure 39: EPI Monitoring graph 2004...... 79 Figure 45: Major Outpatient Diseases Reported KNH 2002 - 2004 ...... 138 Figure 49: Age Distribution by Place of Cholera Outbreak ...... 154 Figure 50: Percentage of effectiveness of drugs...... 156 Figure 54: Percentage Distribution of Workforce by Facility type...... 211

vii Annual Report 2003 - 2004 Abbreviations ALS Average Length of Stay ASAL Arid and Semi-Arid Lands BCG Bacille Culmette Guerin (vaccine against tuberculosis) CBS Central Bureau of Statistics CHANIS Child Health and Nutrition Information System DOMC Division of Malaria Control DPT Diphtheria Pertussis Tetanus (vaccine) DORH Division of Reproductive Health ECHA Education for Community Health Action EPI Expanded Programme on Immunization ERSWEC Economic Recovery Strategy for Wealth and Employment Creation FAO Food & Agricultural organisation FP Family Planning GDP Gross Domestic Product GMP Growth Monitoring Programme GNP Gross National Product GOK Government of Kenya HMIS Health Management Information System HR Human resource ICD International Classification of Diseases IFAD International Fund for Agricultural Development. IMCI Integrated Management of Childhood Illness IRS Indoor Residual Spray IDSR Integrated Disease Surveillance and Response KCPS Kenya Contraceptive Prevalence Survey KDHS Kenya Demographic and Health Survey KEPI Kenya Expanded Programme on Immunization KNH Kenyatta National Hospital MCH Maternal Child Health MDG Millennium Development Goals MoA Ministry of Agriculture MOH Medical Officer of Health MoH Ministry of Health MPND Ministry of Planning and National Development NCPD National Council for Population and Development NHA National Health Accounts NHSSP National Health Sector Strategic Plan OPD Out-Patient Diseases OPV Oral Polio Vaccine PGH Provincial General Hospital PRSP Poverty Reduction Strategy Paper RHCs Rural Health Centres TT Tetanus Toxoid TOT Training of Trainers UNICEF United Nations Children's Fund USAID United States Agency for International Development WFP World Food programme WHO World Health Organization

viii Annual Report 2003 - 2004 FORWARD

This detailed Health Performance Annual Report presents the major causes of ill-health and various outputs as performed by the Ministry of Health and the entire Health Sector. It also shows the resources generated and allocated to the health sector.

The primary objective of the 2003 and 2004 Annual report was to provide updated information for policy makers, planners, researchers, programme managers and Health workers, which would allow guidance in the planning, implementation, monitoring of health interventions and population based health programmes. The report 2003/04 represents information analyses of various health issues covering the period 2003 and 2004 with some comparative trends from 2000 in some areas. Most data have been disaggregated to provincial and district levels while specialized services data have been presented by reporting facilities.

Tremendous efforts have been made to improve the reporting in all the subsystems. However, not all health facilities, districts and programmes reported as expected due to various constraints. Despite the incompleteness of reporting, useful information are presented here forth with. Analysis of numerical data for knowledge, predictions or action has been shown with comparative information from districts displayed using tables, graphs, charts, thematic maps and descriptive statistics.

Data for instance, finance, personnel and specialized services have been included. In addition data from Kenya Demographic and Health Surveys and the economic surveys, ERS have been used to compare with the HIS data reasonable trends.

All governments need good statistics; the need is particularly acute where resources are limited and the cost of unwise allocation of funds can mean the difference between survival and death. Reliable and timely health information is an essential foundation of public health action. Investment in the systems for data generation – collection, analysis, dissemination and use will provide timely information to identify problems and needs, track progress, evaluate the impact of interventions and make evidence-based decisions on health policy, programme design and resource allocations.

Reporting on progress towards achieving specified targets for specific indicators has become more important with the introduction of performance based disbursement in several country and Global initiatives such as GAVI, GFATM, RBM, MDGs among others. The efforts to control major diseases need holistic and comprehensive approaches. Health information systems can provide the “glue” to bring together individual and community health interventions.

In the context of Health Sector Reform and decentralization with shift to SWAp approach, health systems are managed as close as possible to the level of service delivery. This shift in functions between the central and peripheral levels generates new information needs and calls for an in-depth restructuring of information systems with changing data collection, processing, analysis and dissemination requirements with one Monitoring and Evaluation framework.

The major challenges to the Monitoring and Evaluation as proposed in the current framework, is the need for standardization and quality health information which the MoH is addressing by the central level. It is equally urgent for development partners to work towards more harmonized approaches aligned with the national health information system.

The division of Health Information System will disseminate the information to all who need it through print and electronic media. The Ministry of Health has already set up its own website which will provide instant information electronically to local and international organizations and individuals. We hope to host future annual reports on our website on time.

It is hoped that the production of this report will stimulate all the districts to make substantial efforts in the collection, analysis and utilization of data for action. At the national level a Health Information System steering committee has been established with the aim of strengthening country health information that is population based, administrative and facility based data. HMIS invites the users of the data and analyses in this report to freely comment on its contents, presentations and format as this will reveal the areas where gaps exist.

ix Annual Report 2003 - 2004 Finally, there is increasing demand for health status data that is mortality which will be come as a separate report, morbidity and well-being. HMIS looks forward to accommodate data generated by other departments such as Civil Registration, private providers research in future reports in an effort to making integration of data a reality as envisaged in the Ministry of Health’s Kenya Policy Framework of 1994 – 2010 and the NHSSP II 2005- 2010.

DR. JAMES NYIKAL MBS DIRECTOR OF MEDICAL SERVICES MINISTRY OF HEALTH

x Annual Report 2003 - 2004 ACKNOWLEDGEMENTS:

The Health Management Information Systems wish to gratefully acknowledge the contribution of and thank:

v Dr. Hezron O. Nyangito, Permanent Secretary and Dr. James Nyikal MBS, Director of Medical Services, for their support and technical advice in preparing this report.

v The Ministry of Health Heads of Departments, Divisions and programme managers whose activities have been included in this report.

v The Provincial Health Management Teams (PHMTs) and District Health Management Teams (DHMTs) for ensuring and facilitating the sending in of the routine and surveillance data to HMIS.

v We are grateful to all Health facility health workers for providing the data in spite of the numerous constraints and difficulties.

v Special thanks to Dr. E.A Ogara, P. Wanjala, K. Ngotho and G. Kimani for the compilation of this report. Your efforts have yielded results.

v Finally, we acknowledge the collaborative and financial support from the National Statistical System (NSS) project (STATCAP) by accepting to print this Health performance Annual Report 2003 and 2004.

xi Annual Report 2003 - 2004 EXECUTIVE SUMMARY

The health Performance Annual Report presents the major causes of ill-health and various outputs performed by the Health sector in 2003 and 2004. Detailed trends have been reflected to elaborate on districts’ situational analysis. Reliable and timely health information is an essential foundation that will provide guidance for evidenced decision making.

The expenditure for health (Recurrent and Development ) increased by 36% in the four year period from 12.1 billion in 2000/01 to Kshs.16.4 billion in 2003/04 and 54% of the total amount spent on health came from private sources (NHA, 20001/02). Personnel costs accounted for the highest share of the MOH spending at approximately 53%, while grants to health providers KNH and Moi National hospitals accounted for 19% of the total public health spending. The expenditure of the government health budget had been closely related to curative health services with over 10 per cent of total expenditure on rural health services while additional 8 percent went to health training and research.

The total revenues collected under cost sharing (FIF) released Kshs.1, 004.9 million against an estimate of Kshs.1, 085.5 millions. NHIF expenditures were Kshs 2,245 million against a total contribution of Ksh.2, 639 million. A distinctive feature of Kenya’s health cost-sharing programme has been the reservation of 25% of its revenues for district – focused preventive and promotive health interventions, including elements of PHC, health education, environmental health, control of communicable diseases like Tuberculosis, STIs, essential drugs and mental health among others.

The KDHs 2003 showed some decline in health status trends and service delivery. Maternal mortality rate reduced from 590-414 per 100,000 live births, while the deliveries by skilled attendant dropped from 42.1% to 40.1% in 1998 and 2003 respectively.

The lending cause of out-patient morbidity in the country during 2004 was Malaria which accounted for 33% of the total cases reported. The diseases of respiratory systems 24%, disease of the skin 7%, diarrhea disease 5% intestinal worms 5%, Pneumaonia 3%, Accidents 2%, Rheumatisms 2%, UTI 2% and eye infection 2%. All others contributed to 15% of the total reported causes.

The rate of malnutrition ranged between 7% - 17%, the percentage of children with started growth between 2.4 – 13.8% by province. The highest provinces with high malnutrition rates in 2004 were Rift Valley, Coast and North Eastern 20% while Nairobi had no report for 2004. On Child Health, 34% of the districts are now implementing IMCI strategy. The division of malaria Control supported 16 districts with epidemic prone (sentinel districts) with various Interventions such as residual indoor spray, mapping of high risk areas and supporting district to determine their thresholds.

Various disease outbreaks were also reported throughout the country i.e. Cholera, afloxicosis, leptospirosis, typhoid and up-search of highland malaria in malaria epidemic districts. The HIV prevalence was high with 41% reported in Suba district. However, the national trend reduced from 13.4% in 2000 to 9.4% in 2003. The uptake of VCT went up from 18,151 to 334,795 with a marked reduction of the percentage positive cases from 18.75% to 14.87% in 2001 to 2004 respectively.

The PMTCT uptake has not taken off in North Eastern province and almost 30% of mothers tested HIV Positive accepted to be put on Nevirapine treatment. The acceptance was generally low.

On immunization, the 2004 verification index (data) by the Data Quality Audit team indicated almost double in the EPI verification factor of 86% up from 49% in 2002. This indicated that Kenya’s EPI data was reliable. Penta one (1) coverage was 84% down from 87% in 2003 indicating a reduction in accessibility of the EPI services while measles coverage also reduced from 69% to 65% in 2004 indicating poor utilization. However, this was an increase from the 2002 where both the accessibility and utilization was poor. There was also reduction in Disease Surveillance of the AFP, Measles and MNT in comparison to 2000 – 2003 and the trend is likely to go down further.

A total of 95,755,977 male, 619,093 female condoms were distributed in 2004. This was up by 35% for males and over 2000% for females in 2000 to 2004 respectively. The other preferred modern FP methods were injectables and low dose of pills with over 3 million pills distributed, The Physiotherapy, Orthopaedic, Occupational Therapy and Mental health services showed an increased service provision, while the number of specialist remained the same with some reducing due to natural attrition. The disability prevalence’s were highest among the males than the females in all the age groups and most common in ages 6-23 years of age. All these services require moree resources to be allocated to.

On ophthalmic services, 73 eyes clinics were supported throughout yhe country, which had a total of 540,557 patients seen which was up by 50% from 2000 and 2004. The specialized services on the other hand released about 20% of service capacity due to machine breakdowns.

Facility utilization and services provided to in patients realized over 100% bed occupancy rates in Maragua district hospital (102%) central Province, Kinango District Hospital (128%), Malindi district hospital (110%) in Coast province, Isiolo district hospital (200%), Mbeere district hospital (187%), Mwingi district hospital (120%) and Kitui district hospital (108%) all in Eastern Province. In Nairobi, Mathare hospital had occupancy rate of 110% while in North eastern, Wajir district hospital has 130% occupancy rate. In Nyanza Province, Gucha district hospital had bed occupancy of 128%, Rachuonyo district hospital 130%, Kisii district hospital 166% and Kisumu district hospital 158% as the facilities reporting high occupancy rates.

In Rift valley, laikipia district hospital 132% and Turkana district hospital 130% are the only facilities reported high occupancy rates. While in Western Province, Bungoma district hospital 110%, Butere/Mumias 111% and Teso District hospital 120% as hospitals with high bed occupancy/overcrowded and need expansions. However, the distribution of the number of beds in most facilities has significant impact on the distribution of health personnel.

There were minimal activities reported towards the health promotion and disease prevention by programmes/divisions carrying out the interventions and some not participating in these report. The notable key in Disease prevention are Environmental Health, National Tuberculosis and Leprosy Programme (not included in this report), health promotion.

On staff mapping exercise, a total of 34,986 health personnel were realized indicating a sex ratio of 1 to1.24. The concentration of staff in facilities showed that district hospitals had 48.0%, health centres with 16.0% and dispensaries only accounting 11.o% of the personnel.

The ratio of nurse to one doctor is on average 26 per doctor with minimum of 2 and maximum of 108 per the doctor. Average nurse density per 100,000 people in the capital city is 132 while average nurse density per 100,000 populations outside capital city is 60. The average of all human resource in health per density of 100,000 populations in the capital city minimal of 166 while entire country is 69.4%. The man power shortage is the imbalance that has developed between the expansion of the health sector services, infrastructure and the limited development of capacities for health personnel.

Every one counts better information, better decisions, better health

ii Annual Report 2003 - 2004 1. Chapter 1 – Country Profile

1.1 Introduction

1.1.1 Location and Administrative units

Kenya is located in East Africa and lies approximately between latitudes 4.2 degrees North and 4.28 degrees South of the equator, and between longitudes 34 degrees East and 42 degrees East. It is bounded by Tanzania to the south, Uganda to the west, Sudan to the northwest, Ethiopia to the north, Somalia to the northeast and the Indian Ocean to the east.

Figure 1: Administrative Map

Kenya has 8 provinces namely Nairobi, Central, Coast, Eastern, North Eastern, Nyanza, Rift Valley and Western. Major Cities/ towns are: Nairobi - 2,143,254 (1999 census), Mombasa - 665,018, Kisumu - 322,734, Nakuru - 231,262.

Area: Total: 592,909 sq km Land: 581,679 sq km Water: 11,230 sq km

1.1.2 Political Organisation

Kenya achieved self-rule in June 1963 and gained independence from Britain on December 12, 1963. Exactly one year later, Kenya became a republic under an executive President who is both the head of State and the head of Government. The country has had a stable government and political tranquillity since becoming independent. The country was a multiparty state until 1981, when the relevant parts of the constitution were amended to create a one-party state.

However, in the early 1990s, the country reverted to a multiparty state. From the start of its independence until December 2002, the Kenya African National Union (KANU) ruled the country. During the 2002 general elections, the National Alliance of Rainbow Coalition (NARC) ascended to power through a landslide victory. Kenya is divided into 210 parliamentary constituencies each represented by a Member of Parliament (MP). In addition to the 210 MPs, there are 12 Nominated Members allocated to each party represented in Parliament, on the basis of the number of elected seats of each such party.

1.1.3 Topology and geology

The country can be divided into seven topographical regions: (1) The coastal strip; (2) The Nyika and Tana Plains which are thorn scrub bush lands; (3) The eastern plateau which includes the Amboseli, as well as the Chyulu Range and Taita Hills; (4) The vast northern plains that account for 60% of the land area and are a series of arid plains; (5) The Kenya Highlands, comprising one of the most successful agricultural production regions in Kenya;

1 Annual Report 2003 - 2004 (6) The Rift Valley with the basin consisting of a series of extinct volcanoes and the lakes of Naivasha, Elmentaita, Nakuru, Bogoria and Magadi and; (7) The western plateau, which descends into Lake Victoria.

The principal rivers are the Tana and Athi. The arable areas cover nearly 20% of the country and provide the main livelihood for most of the population.

1.1.4 Climate

Kenya's climate varies from a tropical climate on the coast characterized by hot and humid conditions to a temperate climate inland and to a dry climate in the north. Over 70% of the country is arid and semi arid receiving less annual precipitation while rainfall is greatest in the highlands. Most parts of the country experience a bimodal pattern of rainfall, with the long rains coming in March- May and the start of the short rains occurring through October – December.

Altitude is a major factor in variations in temperature between the different regions of the country. Average temperature ranges in Nairobi are from 11 to 23 degrees Celsius in July to 12 to 28 degrees Celsius in February.

1.2 Trends in Socio-economic development

1.2.1 Economic Trends

According to 2003 statistics1, agriculture, which is the mainstay of Kenya’s economy, accounted for 24% of the gross domestic product (GDP), industry 16% and services 60%. Tea, horticulture and coffee in that order are the main agricultural based foreign-exchange earners.

Kenya is well committed to reforms and sound economic policies. In 1993, the Government of Kenya implemented a program of economic liberalization and reform that included the removal of import licensing, price controls, and foreign exchange controls.

The reforms led to a brief turnaround in economic performance following a period of negative growth in the early 1990s. Kenya's real GDP grew 5% in 1995 and 4% in 1996, and inflation remained under control. Growth slowed in 1997-99 however.

A severe drought from 1999 to 2000 compounded Kenya's problems, causing electricity rationing and reduction in agricultural output while growth in the manufacturing slumped as a result of competition from cheap imports, dilapidated infrastructure and lower aggregate demand. As a result, GDP contracted to 0.2% in 2000. Despite the return of strong rains in 2001, weak commodity prices limited Kenya's economic growth to 1.2 percent. Kenya saw a growth of 1.8 percent in 2003 from 1.2% in 2002.

There has been a steady increase in current GDP per capita from KSh 21,737 in 1999 increasing to KSh 24,902 in 2001 and further to KSh 30,075 in 2003.

Consumer price inflation averaged 9.8 percent in 2003, almost a full 8 percentage points higher than 2002 (2%).

1.2.2 Demographic features

Population projected estimates for Kenya explicitly take into account the effects of mortality due to AIDS. This can result in lower life expectancy, higher infant mortality rates, lower population growth rates, and changes in the distribution of population by age and sex.

1 Central Bureau of Statistics: Economic Survey, 2004 2 Annual Report 2003 - 2004 Recent data sources including the 1999 Kenya Population and Housing Census, 2003 Kenya Demographic and Health Survey, the National Health Accounts, Kenya Household Expenditure and Utilization Survey contribute to an understanding of the health and determinants among the Kenyan population.

The estimated projected population of Kenya in 2003 was 32.2 million, increasing to 32.8 million in 2004. The population is relatively youthful with 41% of the population being under the age of 15 years on the basis of 2004 population. On the other hand, the number of persons aged 65 years and over represented about 4% of the population in 2004 (Table 1). The female population in the reproductive age group that is between the ages of 15 and 49, made up 49.8% of the total female population or 25.6% of the total population. Clearly, health care services must cater for a wide range of needs, having to provide maternal and child health services as well as geriatric services and everything that comes in between. Population based efforts to promote healthy aging will need to be strengthened to reduce the demands on health services. The population is projected to increase to 34.7 million by 2007 and further to 36.5 million by 2010.

Table 1: Kenya - Summary of age structure (2004)

Age group Male % Female % Total % Ratio (Male/female) 0-4 years 2,373,938 14.9 2,470,788 14.6 4,844,726 14.8 0.96 5-14 years: 4,279,051 26.8 4,421,634 26.2 8,700,685 26.5 0.97 15-49 years: 7,779,649 48.8 8,393,468 49.8 16,173,117 49.3 0.93 50-64 years 877,311 5.5 893,332 5.3 1,770,643 5.4 0.98 65 years and 627,921 3.9 691,176 4.1 1,319,097 4.0 0.91 over:

Total 15,937,870 100.0 16,870,398 100.0 32,808,268 100.0 0.94 % 48.6 51.4 100.0

Females accounted for 51.4% of the population in 2004 most likely as a result of slightly longer life expectancy of females compared to that of the males. Females predominated in all the age bands. Overall, the ratio of 1 male to 1.1 females was derived for the 2004 population.

The population aged 0 - 14 years is, strictly speaking, primarily a consuming population. Together with the population aged 65 years and over provide the dependent population as distinct from the labour force, that is, the population aged 15 - 64 years. Thus, the dependency ratio2, which indicates the burden on the potentially “working” population of the needs for education, health and other essential services of the dependent group, was 83% in 2004. This figure corresponds to about every four dependants being supported by five persons of working age.

The population has grown at a level of 2.9% during the intercensal period of 1989-1999, declining from 3.4% in the 1979-1989 periods. In 2004, it was estimated that the population growth rate was 2.0%3. The basic socio-demographic characteristics are shown in Table 2.

2 Dependency ratio = Number of population aged 0-14 years plus Population aged 65 year and over x 100 Number of population aged 15-64 years

3 Central Bureau of Statistics: Analytical Report on population Projections, Volume VII. Kenya 1999 Population and Housing Census 3 Annual Report 2003 - 2004 Table 2: Social-demographic characteristics, Kenya

DESCRIPTION NAIROBI CENTRA COAST EASTERN NORTH NYANZA RIFT WESTERN TOTAL L EASTERN VALLEY Area (km2) 696 13,220 82,816 153,473 128,124 12,547 182,539 8,264 581,679 Area as a % of total area of Kenya 0.1 2.3 14.2 26.4 22.0 2.2 31.4 1.4 100.0 Average household size (1999) 3.2 4 4.7 4.8 5.6 4.5 4.6 4.8 4.4

Population [2004] 2,656,991 4,012,434 2,866,934 5,070,099 1,358,300 4,857,210 8,169,852 3,816,448 32,808,268 Population % by province [2004] 8.1 12.2 8.7 15.5 4.1 14.8 24.9 11.6 100.0

Population [Male] 2004 1,370,328 1,899,722 1,264,408 2,493,636 653,372 2,310,117 4,064,393 1,881,894 15,937,870 Population [Female] 2004 1,286,663 2,112,712 1,602,526 2,576,463 704,928 2,547,093 4,105,459 1,934,554 16,870,398 Sex ratio [Males per 100 females 106.5 89.9 78.9 96.8 92.7 90.7 99.0 97.3 94.5

Population density (people per km2) [2004] 3,818 304 35 33 11 387 45 462 56 Urban percentage (1999) 99.2 13.9 35.1 5.8 14.9 10 13.4 8.3 19.4 Household headed by Females [%] 24.3 37.6 30.6 39.7 30.9 43.5 36.3 39.7 36.7 Intercensal Population Growth 4.8 1.8 3.1 2.1 9.5 2.3 3.4 2.8 2.9 rates % (1989-1999) Crude Death Rate - (CDR) [1999] 9.3 8.7 12.1 9.8 7.7 19.0 8.6 14.5 11.7 Crude Birth Rate - (CBR) [1999] 32.0 33.0 42.8 40.8 48.6 45.8 44.7 45.0 41.3 Life Male 54.1 60.4 52.0 57.6 62.2 41.7 59.1 49.8 52.8 Expectan cy at Female 59.8 68.0 58.3 65.5 61.5 48.0 66.4 55.8 60.4 Birth [1999] Infant Mortality Rate (IMR) [1999] 49.7 36.9 86.2 44.1 65.1 111.6 50.9 100.6 77.3 Under 5 Mortality Rate ((U5MR) 93 66 139 79 103 192 89 159 116 [1999] The province with the largest population is the Rift Valley province, followed by Eastern. North Eastern has the least population. North Eastern, Nairobi, Rift Valley and Coast have experienced higher than average intercensal population growth. Growth was highest in North Eastern province where the percentage is 9.5%.

1.3 Trends in Health Status Indicators

Despite the positive aspects of some key health indicators, many health indicators appear to have reached a plateau, yet others have worsened. However, efforts continue to be made to monitor progress toward achieving the Millennium Development Goals (MDGs), three of which are the responsibility of the health sector. Figure 1 shows the trends in vital indicators. A gradual fall in crude death rate from 17 to 11 per 1,000 populations and the persistently high crude birth rate (over 40 per 1,000 populations) has driven the growth in population. The total fertility rate rose from 6.7 in 1948 to 7.9 in 1979 before dropping back to 6.7 in 1989 and further to 4.8 in 2003.

The life expectancy at birth rose to reach a peak at 60 years in 1989 from 50 years in 1969. In 1999 the life expectancy was 56.6 years [male expectancy was 52.8 years and 60.4 years for females]. There is evidence that the life expectancy has now fallen and is estimated at 47 years.

Figure 2: Vital rates

. C rude De ath Rate P o p u la tio n [m illio n ] 17 20 14 11 40 15 1 1 .7 10 20 5 0 1969 1979 1989 1999

0 1969 1989 2003 2005 2007

T o ta l F e rtility R a te Life E xpe ctancy [years]

10 80

7 .6 7 .8 60 60 8 54 57 6 .7 50 47 40 44 6 35 5 4 .8 20 4 0 2 1948 1969 1989 2003 0 1969 1979 1989 1999 2003

Crude Birth Rate Infant and Under Five Mortality

150 60 50 100 40 50 54 48 50 30 41 20 0 1969 1979 1989 1999 2003 10

IMR 119 88 66 77 77 0 U5M R 115 113 116 115 1969 1979 1989 1999 1.3.1 Childhood Mortality

During the first two decades after independence in 1963, Kenya saw rapid decline in infant and under five mortality in the 1970s and early 1980s. However, the 1990s saw an upsurge in infant and child mortality. Table 3 presents the trends in infant and under five mortality. Male children were more likely to die before their first and fifth birthdays compared their female counterparts; with the gap between male and female mortality rates widening in the recent past.

Large regional differentials are evident while differences in mortality between urban and rural also emerge clearly. The rise in childhood mortality rate has been attributed to the HIV/AIDS pandemic, poverty and the general decline in economic performance among other factors.

Table 3: Trends and differentials in Infant and Under-five Mortality rates 4 (per 1000 live births)

KDHS 1989 KDHS 1993 KDHS 1998 1999 Census 2000 MICS KDHS 2003 - - five five five five five five ------ortality Infant 1989] 1989] Infant Infant Infant Infant Infant [1979 [1979 Mortality Mortality Mortality Mortality Mortality Mortality Mortality M Mortality Mortality Mortality Mortality Characteristic Under Under Under Under Under Under Residence Urban 56.8 89 46 75 55 88 n.a. n.a. 59 90 61 93 Rural 58.9 91.2 65 96 74 109 n.a. n.a. 73.3 115 79 117 Gender Males 63 96.1 67 97 75 108 n.a. n.a. 74.5 114.3 84 122 Females 54.3 85.7 59 89 67 103 n.a. n.a. 65.3 104.7 67 103 Province Nairobi 46.3 80.4 44 82 41 66 49.7 93 51.3 77 67 95 Central 37.4 47 31 41 27 34 36.9 66 36.3 50 44 54 Coast 107.3 156 68 109 70 96 86.2 139 65.3 101.3 78 116 Eastern 43.1 64.3 47 66 53 78 44.1 79 57.3 78.3 56 84 Nyanza 94.2 148.5 116. 128 187 135 199 111.6 192 7 194.7 133 206 Rift 34.6 50.9 valley 45 61 50 68 50.9 89 48.3 72 61 77 Western 74.6 132.8 64 110 64 123 100.6 159 86.7 140 80 144 Kenya ? / 63 93 71 105 77.3 116 73.3 116’ 77 115 Source: KDHS 1989, KDHS 1998 pg 94; MICS 2000, pg 12;

National averages, however, mask considerable variation among the various wealth index quintiles. Recent data [KDHS 2003] suggest that the link between wealth quintiles and mortality is strong (Figure 3). For example, under-five mortality in the lowest quintile is more than 1.5 times that of the highest quintile.

4 Mortality rated have been computed over ten year period preceding the surveys. 6 Annual Report 2003 - 2004 Figure 3 Infant and Under 5 Mortality Rates (KDHS 2003) by Wealth Quintiles

160 149 140 121 120 109 100 96 91 82 80 75 77 62 60 53

Per 1,000 live births 1,000Per 40 Lowest Second Middle Fourth Highest Wealth Quintiles IMR <5MR

1.3.2 Maternal Mortality

Table 4 shows the trends in maternal mortality ratio (MMR) in Kenya. There is, however, lack of regional estimates of maternal mortality. The Maternal Mortality ratio for Kenya was estimated at 414 per 100,000 births for the period 1993-2003.

Table 4: Trends in Maternal Mortality

Description 1994 1998 2003 Maternal mortality ratio 365 590 414 Per 100,000 live births [1988-1994] [1988-1998] [1993-2003] Source: KDHS 1998, 2003 Periods in parenthesis refer to years for which the estimate is applicable

Causes of maternal deaths are varied. Most of maternal deaths are, however, due causes directly related to pregnancy and childbirth — unsafe abortion and obstetric complications such as severe bleeding, infection, hypertensive disorders, and obstructed labour. Others are due to causes such as malaria, diabetes, hepatitis, and anaemia, which are aggravated by pregnancy.

1.3.3 Fertility levels

Evidence from trends in fertility levels indicates high fertility in Kenya with wide regional differentials (Table 5). In particular, most geographic regions show an increase in fertility rates since late 1990s.

7 Annual Report 2003 - 2004 Table 5: Trends in Total Fertility Rates by Residence and Province

Residence/province 1989 KDHS 1993 KDHS 1998 KDHS 1999 2003 KDHS [1986-88] [1990-92] [1995-1998] Census [1995-1998]

Residence Urban 4.5 3.4 3.1 2.7 3.3 Rural 7.1 5.8 5.2 5.8 5.4 Province Nairobi 4.2 3.4 2.6 3.0 2.7 Central 6.0 3.9 3.7 3.8 3.4 Coast 5.4 5.3 5.1 5.2 4.9 Eastern 7.2 5.9 4.7 5.2 4.8 North Eastern n.a. n.a. n.a. 7.0 7.0 Nyanza 6.9 5.8 5.0 5.5 5.6 Rift Valley 7.0 5.7 5.3 5.8 5.8 Western 8.1 6.4 5.6 6.0 5.8 Total 6.7 5.4 4.7 5.0 4.8 Sources: 1989 KDHS; 1993 KDHS; 2003 KDHS; n.a. ± not available

1.3.4 Current contraceptive use

Although there had been major gains in use of contraceptives during the period 1984 – 1998, leading to substantial decline in fertility, contraceptive prevalence rate (CPR) appear to have reached plateau in 2003 at 39% (Table 6). A major challenge is how to tackle the increased unmet need considering the fact that 20% of all births in Kenya are unwanted while 25% of the births are mistimed5.

Table 6: Trends in current contraceptive use Indicator 1984 1989 1993 1998 2003

Contraceptive 15.0 23.2 25.9 29.9 29.5 C Prevalence Rate, All Women 28.4 Any method, (15-49 yrs) Married Women 17.0 26.9 32.7 39.0 41.0 C 39.3 Contraceptive Prevalence Rate, Any All Women 8.1 14.7 20.7 23.6 23.6 C Modern method, (15-49 yrs) 22.7 Married Women 9.7 17.9 27.3 31.5 32.9 C 31.5 Contraceptive Prevalence rate, Any Nairobi 28.3 33.5 45.4 56.3 51.6 method, (15-49 yrs) - currently married Central 34.1 39.5 56.0 61.1 66.8 women Coast 10.5 18.1 20.2 22.1 23.5 Eastern 26.3 40.2 38.4 45.6 49.8 North Eastern n.a. n.a. n.a. n.a. 0.3 Nyanza 8.6 13.8 23.8 28.2 24.3 Rift Valley 15.1 29.6 27.8 37.7 32.9

5 KDHS 2003 8 Annual Report 2003 - 2004 Table 6: Trends in current contraceptive use Indicator 1984 1989 1993 1998 2003

Western 4.6 13.7 25.1 30.2 32.7

Urban 26.7* 30.5 43.4 49.6 47.3 21.7** Rural 16.0 26.2 30.9 36.2 35.8

C - Excludes all of North Eastern Province and five other northern districts so as to be comparable to previous KDHS, otherwise. Source: KDHS 1989; KDHS 1993; KDHS 2003; KCPS 1984 * Nairobi /Mombasa; **- Other urban

1.3.5 Delivery in health facilities

According to the KDHS 2003, two out of five births (40%) in Kenya took place in health facilities (Table 7). Nairobi had the highest rate of 78% while the lowest was reported in North Eastern (8%).

Table 7: Percentage Distribution of Births delivered in Health Facility Province 1993 1994 1998 2003 KDHS WMSII KDHS KDHS Nairobi 79 80.9 75.6 77.9 Central 72.5 75.5 69.2 66.9 Coast 30.9 32.7 33.0 31.2 Eastern 45.9 52.5 49.0 37.7 North Eastern n.a. 2.8 n.a. 7.7 Nyanza 37.6 47.6 35.6 36.2 Rift Valley 38.9 36 36.1 35.9 Western 32.6 32.4 26.6 28.4 KENYA 44 47.2 42.1 40.1 Sources: KDHS 2003 pg 130;

1.3.6 Social determinants of health

1.3.6.1 Education and literacy rates According to 1999 population census, 18% of the population had never attended school - a matter of concern considering the importance of education in promoting health of individuals. This indicator, however, obscures the fact that since 2003; there has been enormous enrolment to primary education, as part of implementation of free primary education policy introduced by the new government.

9 Annual Report 2003 - 2004 The literacy rate in the population aged over 15 years has shown a gradual increase from 54.3% in 1988 to 73.6% in 2000 and further to 88% in 2003. Table 8 shows that illiteracy among females is almost twice (21 percent) that of males (12 percent).

Table 8: Level of literacy by gender, Kenya 2003

Residence Female Male Urban 88.5 93.7 Rural 75.2 86.2 Total 78.5 88.1 Source: KDHS 2003

1.3.6.2 Unemployment Unemployment rate 6 has persistently remained high and can be expected to have a serious impact on health, both through negative material impacts as well as negative social factors. Overall, 10% of people of the working age (15-64 years) were unemployed (Table 9). The census analysis showed that Nairobi, Coast, and North Eastern had higher than average rates of unemployment. Urban unemployment increased from 7% in 1978 through 15% in 1986 (Urban Labour Force Surveys) to 18% in 19997. Two factors have largely contributed to the prevailing high unemployment rates in the country. First is the weak performance of the economy, which has largely constrained growth in the wage employment in the private sector. Secondly, public sector reforms have led to restrictive employment, retrenchments and privatisation of non- strategic government institutions resulting in downsizing in the civil service and government parastatals.

Table 9: Unemployment Rates for population aged 15-64 years by province and sex, 1989 and 1999 Residence/Province 1999 Male Female Total Rural 6.6 9.1 7.9 Urban 13.6 23.6 17.7 Nairobi 14.5 25.0 18.5 Central 6.8 7.3 7.1 Coast 12.5 19.4 15.6 Eastern 6.6 10.0 8.3 North Eastern 10.7 35.7 19.0 Nyanza 8.0 8.6 8.3 Rift Valley 7.0 12.4 9.5 Western 6.3 7.5 7.0 KENYA 8.4 11.9 10.1

6 Defined as the number of unemployed people of the working age (15-64years) as a percentage of the total labour force (i.e. employed plus unemployed) 7 The 1999 Population and Housing Census: Analytical Report on Labour Force, Volume IX, August 2002, pg38. 10 Annual Report 2003 - 2004 1.3.6.3 Poverty

Overall absolute poverty 8 level increased from 40% in 1994 to 52.3% (excluding 7 arid and semi-arid districts) in 1997 mainly on account of hard economic times the country faced since 1994. If the entire country had been covered, then the estimated level of poverty would have reached 56.5% in 1997. The urban poverty increased from 29% to 49% during the same period, clearly indicating that poverty is not only a rural phenomenon but also an urban problem (Table 10).

Table 10: Differentials overall absolute poverty by adult equivalent

National poverty line9 1992 1994 1997 National 44.8 40.3 52.3 Urban 29.3 28.9 49.2 Rural 47.9 46.8 52.9

Statistically, poverty affects health in its own right: just being poor increases one's risk of ill health. Poverty contributes to disease and death through its second-order effects; poor people, for instance, are more likely to live in an unhealthy environment. The interactions of disease agents, individual susceptibility, behaviour (which often reflects education), and local environmental condition all bear heavily on health outcomes. Thus, efforts to reduce poverty and create wealth and employment continue to be given outmost prominence by the government.

1.3.7 Development indices

As seen from Table 11, the Kenya’s Human Development Index (HDI) - a composite index measuring average achievement in three basic dimensions of human development—a long and healthy life, knowledge and a decent standard of living - has been decreasing since 1990. Kenya was ranked 146th in 2002, hence one of the worst performers among world countries.

Table 11 : Development indices

Indicator 1975 1980 1985 1990 1995 2000 2002

Human development Index (HDI)10 0.445 0.489 0.512 0.540 0.523 0.513 0.488

8 This encompasses both food and non food basic requirements. 9 Central Bureau of Statistics: ECONOMIC SURVEY, 2000; p199 10 A composite index measuring average achievement in three basic dimensions of human development²a long and healthy life, knowledge and a decent standard of living. Kenya is ranked 146th in 2003, hence one of the worst performers among developing countries.

11 Annual Report 2003 - 2004 2. `Public Sector Health Care Financing and Expenditure

2.1 Financing

Public sector health services are heavily dependent on general tax revenue, and more especially the recurrent component of the budget. To a less extent, the other source of finance is that of user fees. Development Partners finance substantial portion of the development expenditure component.

If health services are to be expanded rapidly in the context of constrained total government resources, there is need either to award health sector a larger slice of the resource pie or to consider alternative funding sources. In relation to alternative financing sources, user fees and national social health insurance (SHI) have continued to receive most attention. The potential for implementing a SHI in Kenya has been the topic of debate in recent years.

There is clearly also scope for using existing resources more efficiently and equitably.

2.1.1 Expenditure

The expenditure for health (recurrent and development) increased by 36% in the four year period from KSh 12.1 billion in 2000/2001 to KSh 16.4 billion in the financial year 2003/2004. Of the total expenditure, recurrent expenditure average 90% (Table 12 and Figure 4). Looking in a different way, the spending rose from about KSh 395.49 (US $5) in 2000/2001 to just over KSh 500 (US$6) per capita in 2003/2004. Spending nevertheless remains at a low level of below 2 percent of the GDP.

The total (both recurrent and development) MoH expenditure as percentage of the GoK expenditure was over 7 percent during the review period. However, the Kenyan health budget expenditure is rather low compared to the 15% target set by the Abuja Declaration of African heads of state in 2000. Figure 4: Trends in Recurrent and Development Expenditures.

20,000 9.01 10 8.33 15,438 9 7.23 8 15,000 7 14,405 6.99 12,715 6

10,000 11,041 5 % 4 KSh KSh Million 3 5,000 2,519 1,003 1,032 945 2 1 0 0 2000/2001 2001/2002 2002/2003 2003/2004

Recurrent Development Total

Table 12: Ministry of Health Expenditures (Gross) KSh million Vote 2000/2001 2001/2002 2002/2003 2003/2004 2004/2005 Estimates Recurrent 11,041 12,715 14,405 15,438 15,952 Development 1,032 2,519 945 1,003 7,659 Total 12,072 15,234 15,351 16,441 23,611 Per Capita KSh 395.49 488.44 481.97 506.05 712.67 Per Capita $ 5.05 6.28 6.29 6.52 9.10 Ministry of Health Expenditure (Gross) as % of Total Government Recurrent 7.67 8.23 8.69 7.76 7.22 Development 4.49 17.18 5.12 2.77 8.83 Total 7.23 9.01 8.33 6.99 7.67 Ministry of Health Expenditure (Gross) as % of GDP Recurrent 1.32 1.38 1.40 1.41 1.29 Development 0.12 0.27 0.09 0.09 0.62 Total 1.44 1.65 1.49 1.51 1.91

2.1.2 Ministry of Health Expenditure by sub Vote

The expenditure of the government health budget has been closely related to curative health services (Table 13). It is notable that nearly 50 percent of total (recurrent and development) expenditure was dedicated to curative health services.

Over 10 percent of total expenditure was on Rural Health Services while an additional 8 percent went to Health Training and Research. Financial sustainability is one of the important concerns of the health sector and hence the Government through the MOH provides block grants to the referral and teaching hospitals for support. By 2003/04, Kenyatta National Hospital and Moi Referral and Teaching Hospital accounted for 15.6% and 3.0% respectively of total recurrent expenditure of the MOH.

13 Annual Report 2003 - 2004 Table 13: Ministry of Health Actual Recurrent & Development Expenditures

Sub-Vote 2000/01 2001/02 2002/03 2003/04 KSh Millions 700.7 587.0 714.8 760.4 Recurrent As % Total MoH Recurrent 6.3 4.6 5.0 4.9 General KSh Millions 16.9 1,193.2 432.5 196.9 110 Admin. And Development As % Total MoH Planning Development 1.6 47.4 45.8 19.6 KSh Millions 717.6 1,780.2 1,147.3 957.3 Total Total as % Total MoH 5.9 11.7 7.5 5.8 KSh Millions 6,080.9 6,758.6 7,677.6 7,768.0 Recurrent As % Total MoH Recurrent 55.1 53.2 53.3 50.3 KSh Millions 98.0 637.2 120.1 206.5 Curative 111 Development Health As % Total MoH Development 9.5 25.3 12.7 20.6 KSh Millions 6,178.9 7,395.8 7,797.7 7,974.5 Total Total as % Total MoH 51.2 48.5 50.8 48.5 KSh Millions 874.4 665.2 632.2 863.6 Recurrent As % Total MoH Recurrent 7.9 5.2 4.4 5.6 Preventive KSh Millions 386.2 134.0 183.4 87.9 Development 112 and As % Total MoH Promotive Development 37.4 5.3 19.4 8.8 KSh Millions 1,260.6 799.2 815.6 951.5 Total Total as % Total MoH 10.4 5.2 5.3 5.8

KSh Millions 1,121.4 1,378.1 1,436.4 1,687.6 Recurrent As % Total MoH Recurrent 10.2 10.8 10.0 10.9 Rural Health 113 KSh Millions 248.8 397.7 198.4 446.1 Services Development As % Total MoH Development 24.1 15.8 21.0 44.5 KSh Millions 1,370.2 1,775.8 1,634.8 2,133.7 Total Total as % Total MoH 11.3 11.7 10.6 13.0

KSh Millions 884.2 1,060.2 1,161.8 1,459.8 Recurrent As % Total MoH Recurrent 8.0 8.3 8.1 9.5 Health KSh Millions 281.6 157.3 10.9 65.6 114 Training and Development Research As % Total MoH Development 27.3 6.2 1.2 6.5

KSh Millions 1,165.8 1,217.5 1,172.7 1,525.4 Total Total as % Total MoH 9.7 8.0 7.6 9.3 Medical 116 Recurrent Supplies KSh Millons 29.6 48.3 34.2 32.0

14 Annual Report 2003 - 2004 Table 13: Ministry of Health Actual Recurrent & Development Expenditures

Sub-Vote 2000/01 2001/02 2002/03 2003/04 Coordinatin g Unit As % Total MoH Recurrent 0.3 0.4 0.2 0.2

KSh Millions - - - - Development As % Total MoH Development - - - -

KSh Millions 29.6 48.3 34.2 32.0 Total Total as % Total MoH 0.2 0.3 0.2 0.2 KSh Millions 1,349.6 1,865.2 2,327.0 2,409.0 Recurrent As % Total MoH Recurrent 12.2 14.7 16.2 15.6

Kenyatta KSh Millions - - - - Development 117 National As % Total MoH Hospital Development - - - -

KSh Millions 1,349.6 1,865.2 2,327.0 2,409.0 Total Total as % Total MoH 11.2 12.2 15.2 14.7

KSh Millions - 352.3 421.5 458.1 Recurrent As % Total MoH Recurrent - 2.8 2.9 3.0 Moi KSh Millions - - - - 118 Teaching Development and Referral As % Total MoH Development - - - -

KSh Millions - 352.3 421.5 458.1 Total Total as % Total MoH - 2.3 2.7 2.8 KSh Millions 11,040.8 12,714.9 14,405.4 15,438.5 Recurrent As % Total MoH Recurrent 100.0 100.0 100.0 100.0 Total KSh Millions 1,031.5 2,519.4 945.3 1,003.0 Development As % Total MoH Development 100.0 100.0 100.0 100.0 Total KSh Millions 12,072.3 15,234.3 15,350.7 16,441.5

2.1.3 Ministry of Health Recurrent Expenditure by Economic Category

Figure 5 shows the percent distribution of public health spending (MoH) by key health care inputs (line items) as reflected in the MoH recurrent (2003/04) Personnel costs accounted for the highest share of the MoH spending at approximately 53% followed by grants to health providers (KNH & MoI) accounting for 19% of the total public health spending. Drugs and pharmaceuticals accounted for about 11%. Issues to do with optimal combination of inputs for service delivery as well as a balance between human resources and other inputs should be considered.

15 Annual Report 2003 - 2004 Figure 5 Percent Distribution of MoH Spending by Economic Inputs 2003/04

Kenyatta National M oi Referral Hospit al Hospit al 16% 3%

Purchase of Plant & Equipment 0%

Ot her Operations & Salaries and Other M aintenance Perso nnel 8% 53% Drugs and M edical Consumables 11%

Transfers, Subsidies and Grant s 9%

Table 14 shows the trends in recurrent expenditures by economic categories. The recurrent spending (53%) had been absorbed by the personnel costs in 2003/04 rising from 48% in 2000/01 occasioned by enhanced civil service allowances during the period.

Table 14: Recurrent (gross) Expenditure by Economic Category KSh millions Category 2000/01 2001/02 2002/03 2003/04 Actual Actual Actual Actual Salaries and Other Personnel 5,251.8 6,639.9 7,798.1 8,100.8 as % Total Recurrent 47.6 52.2 54.1 52.5 Transfers, Subsidies and Grants 848.1 1,027.7 1,157.2 1,454.7 as % Total Recurrent 7.7 8.1 8.0 9.4 Drugs and Medical Consumables 1,680.8 1,476.8 1,349.7 1,716.0 as % Total Recurrent 15.2 11.6 9.4 11.1 Other Operations & Maintenance 1,749.9 1,324.0 1,257.4 1,285.2 as % Total Recurrent 15.8 10.4 8.7 8.3 Purchase of Plant & Equipment 160.6 29.0 94.5 14.6 as % Total Recurrent 1.5 0.2 0.7 0.1 Kenyatta National Hospital 1,349.6 1,865.2 2,327.0 2,409.0 as % Total Recurrent 12.2 14.7 16.2 15.6 Moi Referral Hospital 0.0 352.3 421.5 458.1 as % Total Recurrent 0.0 2.8 2.9 3.0 Total Recurrent (Gross) 11,040.8 12,714.9 14,405.4 15,438.5

2.1.4 Health services

The health system is largely a system of public financing and private provision. Since the introduction of user fees in 1989, reliance on household payments to finance health care costs has led to increasing inequities in access health services.

16 Annual Report 2003 - 2004 National Health Accounts 11 showed that out of the total amount of funds spent on health, 54% of the funding came from private sources12, mainly households (51%) through out-of-pocket spending (45% of total health expenditure) and contributions to insurance schemes (6% ) - (Figure 2.3.) The Government (including Parastatals and Local Councils) funding, accounted for 30%, while the rest of the world (Donors) provided 16% of the total health financing in Kenya. Clearly, the results point out the heavy burden placed on households against a background of high level of poverty. Table 15 provides general NHA summary statistics for Kenya.

Figure 6 the Kenya Health Shilling 2001/02 – Where It Came From

Households Private Companies and 51.1% other Sources 2.3%

Local Foundations GoK (incl. Parastatals) 0.6% 29.6% Not Specified Donors 0.1% 16.3%

11 MoH: Kenya National Health Accounts 2001/02

12 Private sources considered include households, private firms, and local NGOs 17 Annual Report 2003 - 2004 Table 15: General NHA Summary Statistics (2001/2002)

Indicator Value Total Health Expenditure (THE) in Kenyan Shillings (million) 46,989 THE in US $ (million) 598 As a % of GDP 5.1 Health expenditure per capita (KSh) 1,506 Health expenditure per capita (US$) 19.2 Public health expenditure as % of total government expenditure 8

Sources of Funds

Public as a % of THE 30% Private as a % of THE 54% Donors as a % of THE 16%

Household Spending

Total HH spending as a % of THE 51% OOP as a % of THE 45% OOP spending per capita $8.58 or KSh 674

Providers Public health Provider Expenditure 60% Private health Provider Expenditure 39% Other (N.S.K) 1%

Functions ( % of THE ) Outpatient curative care 45.2% Inpatient curative care 32.1% Prevention & public health services 9.1% Pharmaceuticals 7.4% Health administration 5.0% Others (e.g. Capital formation for health care institutions) 1.3% Source: Kenya, Ministry of Health, National Accounts of Kenya, 2001/02; 2005

18 Annual Report 2003 - 2004 2.2 Financial Performance of Cost Sharing Programme

Cost sharing in public health sector was mooted in the 1984/88 Development Plan and implemented in December 1989 to supplement and complement government resources allocated to the health sector. The revenue collecting health facilities are allowed to retain 75% for use in the improvement of their health care service provision. The remaining 25% of the revenue collected go towards financing the promotive and preventive services in the district.

2.2.1 Reporting Rates

Reporting rates are crucial in providing accurate picture of trends in all cost sharing revenue collection aspects. Thus, facilities are supposed to submit monthly reports on revenue collections, banking, payments and commitments, fee schedules, workloads, financial and workload targets.

During financial year 2001/2002, overall reporting rate of 62% was achieved. By province, Coast had the highest reporting rate of 86%, followed closely by Rift Valley (81%) and Eastern (80%). Nairobi and North Eastern provinces had reporting rates of less than 30% (Table 16). Facility wise, decline in reporting rates between 2000/01 and 2001/02 was noted.

Table 16: Reporting rates by facility type and by province Province Provincial District Sub District Health Centres & General Hospitals Dispensaries Hospitals Hospitals 2000/01 2001/02 2000/01 2001/02 2000/01 2001/02 2000/01 2001/02 2000/01 2001/02

Central 100 88 98 79 99 78 80 69 83 79 Coast 97 93 91 84 91 90 59 77 71 86 Eastern 100 91 79 82 92 75 80 65 82 80 Nairobi* - - 35 20 - - 28 12 44 16 North 55 51 53 24 - - 15 11 20 29 Eastern* Nyanza 92 85 81 72 66 73 72 72 73 76 Rift valley 89 89 87 83 86 79 60 74 66 81 Western 84 57 77 28 94 19 79 23 80 52 Kenya 88 80 75 59 88 69 57 50 63 62

2.2.2 Trends in cost sharing revenues

Table 17 shows the cost sharing revenue collection trends by province and year. During the financial year 1996/97, the reported collected revenue was KSh 205.1 million increasing to KSh 714.8 million in 2000/2001 and further to Ksh 1,004.9 million in 2003/04.

The rising trend in revenue collection can be attributed to increased reporting rates by facilities; enhancement, strengthening and efficiency improvements in revenue collection through among others, installation of cash registers in some hospitals with heavy workloads as well as, to a small extent, increases in fee levels. The collection efficiency has been estimated at over 50%? Central, Rift Valley and Eastern provinces dominated the total collections each accounting for nearly a fifth of total revenues collected in 2003/04.

19 Annual Report 2003 - 2004 Table 17: Total reported revenue collections by province and financial year.

Province 1996/97 1997/98 1998/99 1999/2000 2000/2001 2001/2002 2002/03 2003/04 Central 44,007,907 48,311,333 88,784,850 119,831,68 155,810,77 178,789,57 217,162,621 238,274,868 4 9 8 Coast 23,048,250 35,772,209 61,414,792 85,458,454 129,143,36 140,116,77 162,908,844 128,421,043 1 5 Eastern 36,829,751 48,615,407 62,726,864 88,406,813 116,610,28 141,553,73 201,368,007 212,124,032 4 3 Nairobi 8,991,801 8,991,801 11,527,876 23,958,933 25,065,490 24,850,355 35,055,568 28,875,173 N.Eastern 2,982,128 3,031,414 2,371,536 5,331,814 6,918,185 5,432,867 7,203,303 8,616,767 Nyanza 31,656,040 51,636,642 77,452,929 71,840,523 89,128,995 93,873,936 121,472,346 94,276,513 Rift 41,500,077 56,466,438 93,878,943 118,611,34 140,539,56 181,920,59 217,533,412 227,818,073 Valley 1 2 2 Western 16,099,086 20,592,396 26,179,677 32,214,498 51,566,672 16,829,223 70,234,517 66,524,218 Total 205,115,040 273,417,640 424,337,46 545,654,06 714,783,32 783,367,05 1,032,938,618 1,004,930,687 7 0 8 9

The Ministry of Health through the Division of Health Care Financing continues to with activities geared towards enhancing and strengthening revenue collection and efficiency improvements. The activities include installation of cash registers in hospitals with heavy workloads. The revenues that would have been realized if facilities were to report for all months in 2003/04 was estimated at KSh 1.085.5 against a reported revenue of KSh 1,004.9 million.

2.3 National Health Insurance Fund Income & Expenditure Analysis 13

The NHIF was set up in 1966 to provide medical insurance to those employed and earning more than 1,000 Kenya shillings. The main principal activity of NHIF is to receive contributions from its members and pay for them benefits as provided for under NHIF Act. To-date NHIF has a membership of 1.8 million, 100,000 of whom from the informal sector. This paper provides an analysis of income and expenditure of NHIF for the last ten (10) years (1994/95 to 2003/04). This will provide an insight of NHIF in meeting its policy objectives, whether it’s prepared for the proposed transformation and what actions are necessary.

Over the last the ten years the contributions have been increasing from KSh 1,291,008,205 (1994/95) to KSh. 2,734,869,055 (2002/03) which is 110% increase. This upward trend can be attributed to the increase in the number of registered contributors and premiums, which are on average 3% of basic salaries. There has been a steady growth in contributions up to 1998/99. However, the following year (1999/2000), there was a dip decrease before a 25% increase in 2000/01 as shown below.

13 Source: NHIF Annual Report (various) 20 Annual Report 2003 - 2004 Figure 7: Contributions

3,000,000,000

2,500,000,000

2,000,000,000

Amount 1,500,000,000 Contributions

1,000,000,000

500,000,000

- 94/95 95/96 96/7 97/98 98/99 99/2000 2000/01 2001/02 2002/03 2003/04 years

2.3.1 Benefits

The benefit paid to the members in 1994/95 accounted for 83% of the total receipts of the fund. However, from 1995/96 to 2003/04 it has remained below 30% of the total contributions. The lowest level was record in 2000/01 when 16% of the contributions went to benefits – see table 18 below. This calls for efficient management that is adequate to enhance the benefit package necessary required to rising of the premiums. Practice over the other public insurance schemes is to spend over 90% on benefits. The challenge to NHIF is on how to increase expenditures on benefits to acceptable levels as this is the one way of building confidence and attract more members especially from the informal sector.

2.3.2 Personnel

The expenditure on personnel over the periods, 1994/95 to 1998/99 accounted for less than 10% of the total contributions. However, personnel costs have been on the increase reaching 31% of the total contributions in 2003/04. This is a worrying trend and one may need to know whether additional employments were based on need. It is paramount that NHIF is leaner and efficient, and NHIF may not be spared of retrenchment or reorganization in the long -term

2.3.3 Operations and Maintenance

The expenditures on operations and maintenance have been on the up ward trend since 1994/95. However, in 1999/2000, it shoot up to 70% of the total contributions and this can be attributed to, provision for bad debts which accounted for 55% of all the funds spent on operations and maintenance. The combined expenditure on personnel and operations and maintenance account for 57% of the total receipts. The proposed NSHIF bill proposed this level of expenditure be reduced to 10 percent and deliberate effort must be made to start addressing this issue.

2.3.4 Surplus

The surplus grew over the period of 1994/95 and 1996/97 from Ksh. 84 million to Ksh. 1.2billion thus representing an increase of over 1300%. However, the surpluses were consumed in 1998/99 the year NHIF started constructing the new complex. The accumulation of surplus is not desirable and any surplus should have been invested in medical benefits. The expenditure analysis described above confirms that:

21 Annual Report 2003 - 2004 · NHIF is not spending its funds as per policy orientation · Too much is spend on personnel and operations and maintenance at the expense of medical benefits · In light of this effort should be made to make NHIF leaner and efficient as this is one way to build credits especially at this critical stage of transformation.

Table 18: NHIF Income and Expenditure

Year 99/2000 2000/01 2001/02 2002/03 2003/04

Contributions 1,684,347,471 2,145,669,005 2,143,947,712 2,523,876,081 2,639,883,578 Revenue Others 363,101,952 310,859,901 367,608,938 210,992,974 72,358,041 Expendit- ure Benefits 407,890,534 400,281,508 591,383,783 822,014,878 713,292,872 Commissions on sales 5,219,727 10,888,378 12,373,141 42,878 4,559

Admin -Personnel 206,163,982 355,678,955 701,178,892 776,263,163 827,258,377

General -Admin 1,425,597,520 764,838,601 614,517,477 846,506,931 704,478,176

TOTAL EXP. 2,044,871,763 1,531,687,442 1,919,453,293 2,444,827,850 2,245,033,984

Surplus 2,577,660 924,841,464 592,103,357 290,041,205 467,207,635

Table 19: Expenditures as % of contributions

3. 94/95 95/96 96/7 97/98 98/99 99/2000 2000/01 2001/02 2002/03 2003/04 Benefits 82.80 21.70 19.66 23.50 18.04 19.92 16.29 23.55 30.06 26.30 Personnel 3.96 3.96 3.54 3.94 4.37 10.07 14.48 27.92 28.38 30.50 Operations& Maintenance 6.71 8.59 9.31 19.43 16.33 69.88 14.92 24.96 30.95 25.97 Surplus 6.53 65.74 67.48 53.13 61.26 0.13 37.65 23.58 10.61 17.23

22 Annual Report 2003 - 2004 Figure 8: NHIF Income & Expenditure Analysis

90.00

80.00

70.00

60.00

50.00 Benefits % Personnel 40.00 Operations& Maintanence Surplus

30.00

20.00

10.00

0.00 94/95 95/96 96/7 97/98 98/99 99/2000 2000/01 2001/02 2002/03 2003/04 Years

Figure 9: NHIF Income & expenditure Analysis

90.00

80.00

70.00

60.00

50.00 % Benefits 40.00

30.00 Personnel 20.00 and O&M

10.00 Surplus

0.00 94/95 95/96 96/7 97/98 98/99 99/2000 2000/01 2001/02 2002/03 2003/04 Years

23 Annual Report 2003 - 2004 3. Division of Health Care Finance

3.1 Financial Performance of the Cost Sharing Programme

At independence in 1963, the Government of Kenya (GoK) committed itself to providing a full range of free or heavily subsidized quality health services within walking distance for all its citizens as part of its development strategy to improve its people welfare and their productivity. While the initial efforts led to substantive welfare improvements, the onset of the socio-economic crises of the late 1980s undermined the effort, which had been largely Government-funded. Ministry of Health’s (MoH) response to the growing demand for health care had caused the sector to become too large for efficient management, and it soon became evident that the available Government resources were insufficient to fully finance a basic package of cost-effective services.

This was the background against which cost-sharing was mooted in Kenya’s 1984/88 National Development Plan before finally being launched in December 1989. Its main objective was to encourage increased cost recovery as a way of mobilizing additional resources. At inception, patients only paid a registration fee differentiated by facility type, the highest fees being charged at the national referral hospital – Kenyatta National Hospital (KNH) while health centre fees were lowest. A distinctive feature of Kenya’s health cost sharing programme has been the reservation of 25 per cent of its revenues for district-focused preventive and promotive health (P&PH) interventions, including elements of primary health care (PHC), health education, environmental health, control of communicable diseases (like TB, STD and leprosy), essential drugs, mental health and dental health, amongst others. The balance of the revenues (75%) is spent on improvements to the delivery of care, causing the enterprise to be dubbed Facility Improvement Fund (FIF).

3.1.1 Reporting rates

DHCF expects 38 reports annually from each facility involved in the cost-sharing programme. Twelve monthly reports cover workloads, revenue collection and banking, and expenditures. An annual report each is required on services fees and revenue targets. Table 1 provides a summary of provincial reporting rates by facility type for FYs 1999/00 to 2002/03.

Table 20: Facility reporting rates by province – FYs 1999/00 to 2002/03

PGHs DHs SDHs HCs All Facilities Province ABCDA BCDAB CDABC DABCD Central 100 100 95 100 70 98 96 99 67 99 98 100 32 8086963283 93 97 Coast 100 97 87 100 94 91 91 92 9791877460 5987847271 88 80 Eastern 71 100 95 9781799189 7692889561 8080766782 89 80 Nairobi NA NA NA NA NA35-61 NA NA NA NA - 2814324428 14 13 N. Eastern 79 55 45 4261532528 NA NA NA NA 6 15 86 2 15 20 52 28 Nyanza 100 92 82 100 90 81 76 84 7966817871 7276867473 79 78 Rift Valley 95 89 84 100 75 87 79 94 4886969847 6081865266 85 88 Western 100 84 84 9781778184 9894928387 7973678780 75 70 Kenya 92 88 82 9179757779 7688858852 5773665563 72 67 Source: FIS/MoH database, 2003

Note: (i) Facility acronyms as in text; (ii) A – FY 1999/00, B – FY 2000/01, C – FY 2001/02, D – FY 2002/03; (iii) * – Nairobi province does not have a PGH; ** – Nairobi and North Eastern provinces do not have SDHs. Other gaps in data are due to non-reporting.

3.1.2 Revenue

Cost sharing revenue has grown exponentially from KSh. 33 million during FY 1991/92 to KSh. 1.2 billion during FY 2003/2004. These figures exclude collections from Kenyatta National Hospital and Moi Teaching and Referral Hospital. The table below shows collections by province.

24 Annual Report 2003 - 2004 Table 21: Cash revenues by province – FYs 1999/00 to 2002/03

Provinces 1999 Financial years (percentage shares) Percentage increase/(decrease) Population 1999/00 2000/01 2001/02 2002/03 1999/00 2000/01 to 2001/02 to shares to 2001/02 2002/03 2000/01 Central 13.0 21.9 21.6 21.7 21.5 30.0 19.1 16.5 Coast 8.7 15.6 17.9 16.6 16.1 51.1 10.0 13.6 Eastern 16.1 16.2 16.2 17.7 20.0 31.9 30.1 32.6 Nairobi 7.5 4.6 4.2 2.9 3.4 21.3 (17.6) 36.0 North Eastern 3.4 1.0 1.0 0.6 0.7 29.8 (22.7) 34.7 Nyanza 15.5 13.1 12.4 11.7 11.6 24.1 12.5 16.0 Rift Valley 24.4 21.7 19.5 22.0 19.6 18.5 33.5 5.1 Western 11.7 5.9 7.2 6.6 7.0 60.1 10.2 23.1 Totals (KES) 28,686,607 546,760,617 720,116,667 854,414,822 1,003,608,750 31.7 18.6 17.5

The provincial revenue shares over time largely reflected their population shares. While Nairobi has the highest provincial incomes, its comparatively low revenue shares reflect the loss of patients to an expansive private sector. North Eastern’s modest shares might also reflect low populations compounded by the effects of nomadic and general insecurity. Given the historical rigidity of budget allocation shares, greatest concern should lie with heavily populated and high morbidity Western province whose revenue performance falls below its population share.

Table 22: KNH and MTRH revenues – FY 1999/00 to 2002/03

Facility Financial year (percentages) Percentage increase/ (decrease) 1999/00 2000/01 2001/02 2002/03 1999/00 2000/01 2001/02 to to to 2002/03 2000/01 2001/02 KNH 92.2 90.8 75.4 68.7 32.2 -6.6 19.4 MT&RH 7.8 9.2 24.6 31.3 58.8 201.9 66.5 Totals (KSh) 438,531,071 588,834,319 662,608,536 867,812,111 34.3 12.5 31.0 Provincial totals 546,760,617 720,116,667 854,414,822 1,003,608,750 31.7 18.6 17.5 (Table 16) Referral/provincial 80.2 81.8 77.6 86.5 - - - revenues (%)

The final two rows of Table compare the referral hospitals’ aggregate performance against that of all the other facilities in the health cost sharing programme as well as national aggregate revenues. On average over the three FYs, referral hospitals’ revenue growth averaged 28 per cent compared to all the others’ 22 per cent. This growth allowed the referral revenues to average 82 per cent of all other cost sharing revenues and 45 per cent of all MoH revenues. While the higher revenues of referral hospitals might arise from their specialist, higher cost services, poor compliance with referral guidelines also allows the facilities to usurp lower level patients.

3.1.2.1 Revenue Banking Regulations require all facilities to operate bank accounts into which they bank all revenues before any expenditure, which must be authorized by District Health Management Boards (DHMBs). Delays in banking will cause a succeeding period’s banking rate to be over 100 per cent of its revenues. Where facilities violate regulations on prompt banking and spend without DHMB authority, the rate will fall below 100 per cent.

25 Annual Report 2003 - 2004 Table 23: Cost sharing collections vs. banking – FYs 2000/01 to 2002/03

FY 2000/01 FY 2001/02 FY 2002/03 Collected Banked Banking Collected Banked Banking Collected Banked Banking rate rate rate Central 155,810,779 135,813,049 87.2 185,562,706 171,229,487 92.3 216,256,161 206,590,511 95.5 Coast 129,143,361 119,700,592 92.7 142,089,352 135,155,622 95.1 161,459,984 165,035,190 102.2 Eastern 116,610,284 104,684,607 89.8 151,652,882 135,616,407 89.4 201,138,747 175,511,256 87.3 Nairobi 30,398,829 9,908,078 32.6 25,046,917 19,663,300 78.5 34,066,163 33,777,156 99.2 North 6,918,185 5,317,794 76.9 5,345,962 4,241,371 79.3 7,203,303 5,822,659 80.8 Eastern Nyanza 89,128,995 77,099,468 86.5 100,303,761 89,933,864 89.7 116,363,841 113,444,470 97.5 Rift Valley 140,539,562 121,336,545 86.3 187,602,465 165,187,586 88.1 197,188,364 182,946,623 92.8 Western 51,566,672 36,081,417 70.0 56,810,592 42,463,382 74.7 69,932,187 57,783,165 82.6 Totals 720,116,667 609,941,550 84.7 854,414,637 763,491,019 89.4 1,003,608,750 940,911,030 93.8

3.1.3 Expenditure

The chart below summarizes FY 2002/03 spending by all facilities at the provincial level. As with previous FYs, ‘purchase of drugs’ (11%) and ‘purchase of dressings and non-drug pharmaceuticals’ (10%) dominated spending, underscoring the persistent inadequate budget outlays for these items.14 ‘Casual workers’ (8%) and ‘transport’ (8%) also accounted for substantial shares of expenditure. The chart also presents an expenditure category, ‘Others’, which accounts for 46 per cent of all expenditure, a large share requiring disaggregation to guard against surreptitious spending. Besides the 4 per cent expenditure on ‘PHC Activities’, it is conceivable that the other spending categories also promote PHC activities.

Figure 10: National expenditure of cost sharing resources – FY 2002/03

Purchase of Drugs 11%

Purchase of Dressings and Non- Pharmaceutical Items 10%

Others 46% Casual Workers 8%

Transport Operating Expenses 8%

Maintenance of Buildings Purchase of Medical 6% Equipment Purchase of 4% Stationary3% PHC Activities4%

14 Inadequate budget outlays are compounded by extensive resource diversion and/or misappropriation. 26 Annual Report 2003 - 2004 3.1.4 Waivers and exemptions

The basic distinction between waivers and exemptions is that the former largely focus on the socio-economic status of the individual patient while the latter also focus on health status. Waivers must be requested by/for a patient and are awarded on merit, a safety net for access to needed health care on grounds of inability to pay. At any instance, exemption categories (of people or illnesses) are pre-determined and therefore automatic, the number of items covered changing as necessary. Typically, persons exempted include children under 5, some students and institutionalized populations (such as prisoners). Exempted conditions include maternal and child health care, tuberculosis, HIV/AIDS, leprosy and upward and downward referrals. Regulations require that all instances of and justifications for waivers and exemptions are recorded to keep tabs on their significance in access to health care. It is important for revenues foregone under W&E not to be perceived as lost resources if facility managers are not to undermine these provisions’ crucial safety net function in pursuit of revenue maximization.

Table 24: Waivers and exemptions by facility type (percentages) – FY 2002/03

Facility type Waivers Exemptions Inpatient Outpatient workload share workload share PGHs 42.7 11.4 17.6 12.1 DHs 52.5 77.2 67.6 67.2 SDHs 4.9 11.4 14.8 20.7 Totals (KES) 46,930,609 18,872,201 - - Share of total health cost sharing 4.4 1.7 - - revenues including NHIF

3.2 National Hospital Insurance Fund Claims

Membership to NHIF is compulsory for all formal private and public sector employees with a monthly salary of at least KES 1,000. Membership for self employed persons including those in the informal sector is voluntary. While premiums for formal sector employees depend on their salary levels, voluntary members pay a standard rate. The policy provides coverage for each member and their family for part of inpatient costs at accredited public and private health facilities. Reimbursement rates vary according to the bed capacities and structure of fees of individual facilities. Reform proposals since the late 1990s have continued to emphasize the need to make NHIF’s benefit package more competitive, such as by extending coverage to consultation, diagnostics and outpatient treatment. Consultative meetings between NHIF, branches of MoH and other stakeholders have been focused on diminishing bureaucratic red tape to facilitate transactions and popularize the NHIF scheme.

Table 25: NHIF reimbursements in cost sharing resources (KES millions)

Financial Total cash collection NHIF Cash and NHIF NHIF/total year Amount Per cent Refunds Per cent receipts resources per change change cent 1992/93 60.6 - 32.8 - 93.4 35.1 1993/94 116.6 92.4 54.8 67.1 171.4 32.0 1994/95 177.8 52.5 53.0 (3.3) 230.8 23.0 1995/96 237.7 33.7 48.7 (8.1) 286.4 17.0 1996/97 225.6 (5.1) 56.4 15.8 282.0 20.0 1997/98 218.0 (3.4) 58.0 2.8 276.0 21.0 1998/99 384.3 76.3 52.4 (9.7) 436.7 12.0 1999/00 511.1 33.0 44.4 (15.3) 555.5 8.0 2000/01 612.0 19.7 49.0 10.4 661.0 7.4 2001/02 793.4 29.6 60.0 22.4 853.4 7.0 2002/03 1,011.4 27.5 67.3 12.2 1,078.7 6.2

27 Annual Report 2003 - 2004 Table 26: Trainings Carried Out

Title of Course No. Of Health No. Of Districts/Provinces Remarks/Comments Workers Systems Administration 45 8 Provinces Successfully done FIS catch-up Training 30 8 Province, 3 PGHs Successfully done Cash Registers Training 286 7 PGHs, 24 DHs Successfully done DHMB Orientation 176 11 Districts Successfully done Cost Sharing Training 1,480 8 Provinces Successfully done NHIF Consultative Meetings 188 8 Provinces, 7 PGHs, 8 DHs Successfully done

3.2.1 Manuals Developed

The Division of Health Care Financing developed manuals, which are being used for implementation of cost sharing and NHIF claiming during the period under review. These manuals include: · Guidelines for District Health Management Boards, Hospital Management Boards and Health Centre Management Committees; · Operation Manual for Health Centres; · Operation Manual for Hospitals; · FIF Supervision Manual; · Inspection Guidelines for Health Care Financing

3.2.2 Resources

The Division of Health Care Financing has three vehicles:

· GK 105G, Isuzu Trooper (1997) which is serviceable · GK 104G, Isuzu Trooper (1992) which uneconomical to service · GK 983W, Lancer Mitsubishi (1995) which is serviceable

The Division has an annual requirement of Ksh. 3,372,510.00. However, the annual allocation to the Division is Ksh. 639,583.00, which is 19% of the requirement. This has seriously affected the performance of the Division in as far as monitoring and supervision of the cost-sharing programme is concerned. There is severe inadequacy in the areas of servicing and maintenance of vehicles and rehabilitation and maintenance of the building.

The Division of Health Care Financing has had a collaborative partnership with the POLICY Project, which is funded by USAID. Support provided from this source has been targeting systems development, policy analysis and formulation and enhancing efficiency through computerization. The period of this collaboration will be over by end of 2005.

3.2.3 Way forward for division of health care financing

The Division will continue to assist in mobilization of financial resources for health care delivery through efficiency improvements in NHIF (NSHIF) claiming for MoH facilities. Existing structures and systems developed by the Division will be modified to assist in implementation of the proposed National Social Health Insurance Fund. The Division will continue with efficiency improvements in the management of resources in the following areas:

· Building technical capacity to plan and impalement NSHIF or expansion of NHIF; · FIS system maintenance and extension; · Institutionalise training in Hospital Planning, Budgeting and Priority Setting; · Building technical capacity in policy and reform process…

28 Annual Report 2003 - 2004 4. Preventive and Promotive Services

4.1 Nutrition and Growth Monitoring Services

4.1.1 Growth Monitoring and Promotion

Growth monitoring and promotion is a strategy that is aimed at promoting adequate growth of the child through making visual growth of a child to assess the child’s situation. This monitoring concept previously layed much emphasis on the child growth and development in the age bracket 0-5 years and available data indicates that only a small proportion of the children visit the health facilities for Growth Monitoring and promotion. An inter-ministerial approach drawing together the Ministry of Health, Ministry of Education Science and Technology and other stakeholders has been developed and integrated to have the Child Growth and Development Initiative extended to include Children born at home but within the school-going age hence the Integrated Early Childhood Development concept.

The CHANIS Programme conducted several field visits as part of the Nutrition Support Evaluation and monitoring through:-

· Nutrition evaluation and monitoring of the CHANIS system and vitamin ‘A’ supplementation in Mombasa, Kilifi, and Malindi February 2002. · Evaluation and Monitoring of CHANIS and Vitamin ‘A’ Supplementation in Kitui, Mwingi, Garissa, Wajir, Mandera and Ijara Districts June 2002. · Support Evaluation and Monitoring of the CHANIS system and also the introduction of Vitamin ‘A’ Monitoring tools in Coast and Tana River Provinces in December 2002.

Table 27: Percentage of children underweight per district from 2002 to 2004

2002 2003 2004 Under Under Under weight total % weight total % weight total % NYANZA PROVINCE KISUMU 2383 44324 5.90% 5845 113195 5.16% 4548 80895 5.62% SIAYA 678 10200 6.64% 1223 23616 5.18% 1703 27687 6.15% BONDO 940 18944 4.96% 620 11390 5.44% 1509 21846 6.91% KISII 1115 62771 1.78% 2135 70345 3.04% 2104 92849 2.27% NYAMIRA 725 28041 2.59% 2673 31044 8.61% 4659 46137 10.10% GUCHA 1427 83603 17.07% 1589 94202 1.69% 1192 75930 1.57% RACHUONYO 1301 38043 3.42% 933 34370 2.71% 500 17721 2.82% HOMA BAY 2430 44922 5.41% 5003 59500 8.40% 2081 37940 5.48% NYANDO NR NR NR 954 27832 3.43% 4947 89481 5.53% SUBA 794 11828 6.72% 691 8149 8.48% 556 7116 7.81% MIGORI 1317 20650 6.38% 2324 46200 5.03% 145 4879 2.97% KURIA 0 0 0 0 0 0 TOTALS 13110 363326 3.61% 23990 519843 4.61% 23944 502481 4.77% EASTERN PROVINCE EMBU 3226 63661 5.07% 3169 64077 4.95% 3182 75823 4.20% MERU CENTRAL 1229 72326 1.70% 1615 69526 2.32% 1234 70656 1.74% ISIOLO NR NR NR 314 9326 3.37% NR NR NR MAKUENI 3431 84720 4.05% 4301 97972 4.39% 5300 95680 5.54% MWINGI 4123 33469 12.32% 2279 23978 9.50% 1550 17736 8.74% KITUI 1367 22204 6.16% 3841 76509 5.02% 1907 27809 6.86% MACHAKOS 3826 99941 3.83% 6466 116563 5.55% 7550 116751 6.45%

Annual Report 2003 - 2004 29 2002 2003 2004 Under Under Under weight total % weight total % weight total % MARSABIT NR NR NR NR NR NR NR NR NR MERU SOUTH 816 23924 3.41% 1106 36717 3.01% 1376 45283 3.04% MERU NORTH 2481 62175 4.00% 3181 63482 5.01% 3951 100045 3.95% MBEERE NR NR NR NR NR NR NR NR NR MOYALE NR NR NR NR NR NR NR NR NR TOTALS 20499 462420 4.43% 26272 558150 4.71% 26050 549783 4.74%

NORTH EASTERN PROVINCE GARISSA NR NR NR NR NR NR 2456 20345 12.07% IJARA NR NR NR NR NR NR 1074 7966 13.48% WAJIR NR NR NR 100 1205 8.30% 37 708 5.23% MANDERA 932 6183 15.07% 1357 7360 18.44% 1245 6624 18.80% TOTALS 932 6183 15.07% 1457 8565 17.01% 4812 35643 13.50%

COAST PROVINCE MOMBASA 2019 36163 5.58% 2209 31312 7.05% NR NR NR KWALE 8093 68197 11.87% 19467 125526 15.51% 13791 99886 13.81% KILIFI 25580 163092 15.68% 20853 197143 10.58% 19958 195816 10.19% MALINDI 10150 81208 12.50% 8919 84476 10.56% 7697 57832 13.31% TANA RIVER 3401 14451 23.53% 3436 15914 21.59% 732 2625 27.89% TAITA TAVETA 3899 62668 6.22% 4231 68453 6.81% 6545 87725 7.46% LAMU NR NR NR 354 6244 5.67% 268 4587 5.84% TOTALS 53142 425779 12.48% 59469 529068 11.24% 48991 448471 10.92%

RIFT VALLEY PROVINCE NAKURU NR NR NR 367 14305 2.57% 3840 75156 5.09% NANDI NORTH NR NR NR 240 15452 1.55% 443 23092 1.92% NANDI SOUTH 1997 50152 3.98% 593 28291 2.10% 600 25172 2.38% TRANS MARA 135 2779 4.86% 592 13772 4.30% 527 48974 1.08% TRANS NZOIA 410 11272 3.64% 747 19813 3.77% 641 26663 2.40% TURKANA 9204 54834 16.79% 12097 61459 19.68% 15338 102820 14.92% WEST POKOT 1146 24618 4.66% 1829 28492 6.42% 2044 34243 6.00% BOMET 279 6761 4.13% 321 13507 2.38% 141 3270 4.31% KEIYO 1636 33228 4.92% 1536 34949 4.40% 691 28743 2.40% KAJIADO 401 7835 5.12% 213 6546 3.25% 281 6077 4.62% KERICHO 291 5812 5.01% 851 16434 5.18% 677 15831 4.28% LAIKIPIA 985 50989 1.93% 1100 33151 3.32% 4007 62922 6.37% KOIBATEK 700 18737 3.74% 879 23192 3.79% 1258 26218 4.80% NAROK 82 5047 1.62% 193 10040 1.92% 355 19513 1.82% BURET 1597 58067 2.75% 1877 69282 2.71% 330 18820 1.75% BARINGO 442 8825 5.01% 2268 16229 13.97% 3205 43979 1.41% SAMBURU 2885 29405 9.81% 1777 22274 7.98% 1247 24395 5.11%

Annual Report 2003 - 2004 30 2002 2003 2004 Under Under Under weight total % weight total % weight total % UASIN GISHU 712 24352 2.92% 907 35518 2.55% 130 5119 2.54% MARAKWET NR NR NR NR NR NR 10 2088 0.48% TOTAS 22902 392713 5.83% 28387 462706 6.13% 35765 593095 6.03%

WESTERN PROVINCE BUNGOMA NR NR NR 6478 100400 6.45% 6501 107301 6.06% BUSIA NR NR NR 4613 73512 6.28% 7292 113603 6.42% MT.ELGON NR NR NR 425 16663 2.55% 919 26447 3.47% KAKAMEGA 1943 64067 3.03% 4542 122353 3.71% 5759 158669 3.63% LUGARI 323 7618 4.24% NR NR NR 83 4412 1.88% VIHIGA NR NR NR 2099 184257 1.14% 2593 108354 2.39% TESO NR NR NR 3111 36678 8.48% 4057 49992 8.12% BUTERE MUMIAS NR NR NR 1870 54146 3.45% 1049 31855 3.29% TOTALS 2266 71685 3.16% 23138 588009 3.93% 28253 600633 4.70%

CENTRAL PROVINCE MURANG'A 1326 24315 5.45% 1373 23215 5.90% 1659 34744 4.77% THIKA 1458 36507 4.00% 4079 69797 5.84% 1327 45171 2.94% KIAMBU NR NR NR 215 5957 3.61% 211 5463 3.86% NYERI 3074 131801 2.33% 3815 154514 2.47% 4048 164875 2.46% NYANDARUA 2001 88605 2.26% 1713 98953 1.73% 1968 110040 1.79% MARAGUA 1388 44890 3.09% 2339 57544 4.06% 2291 46530 4.92% KIRINYAGA 4698 107012 4.39% 6379 118057 5.40% 6983 165392 4.22% TOTALS 13945 433130 3.22% 19913 528037 3.77% 18487 572215 3.23%

NAIROBI NR NR NR 2098 32918 6.37% 5152 172255 3.00%

Table 28: Percent of children with stunted growth from 2002 to 2004 2002 2003 2004 Stunted TOTAL % Stunted TOTAL % Stunted TOTAL % NYANZA PROVINCE KISUMU 299 17177 1.7 455 33627 1.4 561 21340 2.6 SIAYA 95 2736 3.5 131 6785 1.9 190 5803 3.3 BONDO 683 6100 11.2 14 2810 0.5 103 4502 2.3 KISII 361 12506 2.9 340 11917 2.9 277 16983 1.6 NYAMIRA 146 4954 2.9 1558 5292 29.4 718 6938 10.3 GUCHA 1225 18834 6.5 2595 16475 15.8 202 14926 1.4 RACHUONYO 431 11403 3.8 169 10254 1.6 163 4268 3.8 HOMA BAY 142 9998 1.4 251 11775 2.1 196 8547 2.3 NYANDO NR NR 233 5752 4.1 NR 13946 SUBA 113 2771 4.1 112 3361 3.3 47 1755 2.7 MIGORI 182 7020 2.6 282 12695 2.2 14 2053 0.7 KURIA NR NR NR NR NR NR TOTALS 3677 93499 3.9 6140 120743 5.1 2471 101061 2.4

Annual Report 2003 - 2004 31 Table 28: Percent of children with stunted growth from 2002 to 2004 2002 2003 2004 Stunted TOTAL % Stunted TOTAL % Stunted TOTAL %

EASTERN PROVINCE EMBU 414 8493 4.9 314 24159 1.3 386 7386 5.2 MERU CENTRAL 137 7900 1.7 114 8081 1.4 1575 9024 17.5 ISIOLO NR NR NR NR NR NR MAKUENI 406 14458 2.8 630 7561 8.3 512 14492 3.5 MWINGI 222 8283 2.7 132 5314 2.5 109 3801 2.9 KITUI 251 4350 5.8 801 19881 4.0 246 8873 2.8 MACHAKOS 373 17658 2.1 485 19927 2.4 675 16394 4.1 MARSABIT NR NR NR NR NR NR MERU SOUTH 114 3064 3.7 205 6852 3.0 160 5764 2.8 MERU NORTH 694 22825 3.0 666 14937 4.5 925 23082 4.0 MBEERE NR NR NR NR NR NR MOYALE NR NR NR NR NR NR TOTALS 2611 87031 3.0 3347 106712 3.1 4588 88816 5.2

NORTH EASTERN PROVINCE GARISSA NR NR NR NR 206 984 20.9 IJARA NR NR NR NR 277 NR WAJIR NR NR 22 544 4.0 13 327 4.0 MANDERA 57 1835 3.1 39 2071 1.9 38 2556 1.5 TOTALS 57 1835 3.1 61 2615 2.3 534 3867 13.8

COAST PROVINCE MOMBASA 204 5634 3.6 144 3994 3.6 NR NR KWALE 1484 7609 19.5 1624 27406 5.9 1080 9335 11.6 KILIFI 1693 24313 7.0 1581 21965 7.2 1568 21075 7.4 MALINDI 1124 11356 9.9 1496 39665 3.8 939 9038 10.4 TANA RIVER 504 1514 33.3 507 2838 17.9 42 393 10.7 TAITA TAVETA 351 6016 5.8 474 5866 8.1 785 8149 9.6 LAMU NR NR 94 1088 8.6 46 791 5.8 TOTALS 5360 56442 9.5 5920 102822 5.8 4460 48781 9.1

RIFT VALLEY PROVINCE NAKURU NR NR 44 3447 1.3 706 13091 5.4 NANDI NORTH NR NR 91 2698 3.4 122 4034 3.0 NANDI SOUTH 464 8979 5.2 330 6084 5.4 190 5701 3.3 TRANS MARA 2 924 0.2 43 3865 1.1 324 5961 5.4 TRANS NZOIA 80 2615 3.1 118 5149 2.3 148 8583 1.7 TURKANA 583 6950 8.4 1003 16551 6.1 1573 8666 18.2 WEST POKOT 367 6778 5.4 387 7047 5.5 145 9696 1.5 BOMET 18 2828 0.6 52 5176 1.0 30 967 3.1 KEIYO 461 8400 5.5 399 6420 6.2 329 7834 4.2 KAJIADO 149 1288 11.6 8 27 29.6 33 846 3.9 KERICHO 39 1936 2.0 113 4736 2.4 126 2465 5.1 LAIKIPIA 338 6167 5.5 407 6160 6.6 759 9048 8.4 KOIBATEK 124 3565 3.5 158 4905 3.2 137 4624 3.0

Annual Report 2003 - 2004 32 Table 28: Percent of children with stunted growth from 2002 to 2004 2002 2003 2004 Stunted TOTAL % Stunted TOTAL % Stunted TOTAL % NAROK 15 947 1.6 64 1850 3.5 64 3931 1.6 BURET 245 10526 2.3 313 12647 2.5 61 3019 2.0 BARINGO 57 1432 4.0 174 2736 6.4 433 7970 5.4 SAMBURU 782 4724 16.6 590 4038 14.6 425 4605 9.2 UASIN GISHU 82 5419 1.5 86 5824 1.5 24 923 2.6 MARAKWET NR NR NR NR 4 432 0.9 TOTAS 3806 73478 5.2 4380 99360 4.4 5633 102396 5.5

WESTERN PROVINCE BUNGOMA NR NR 640 19026 3.4 912 22112 4.1 BUSIA NR NR 448 31505 1.4 1267 39808 3.2 MT.ELGON 196 3632 5.4 53 3939 1.3 190 6385 3.0 KAKAMEGA 195 17205 1.1 715 26201 2.7 590 32808 1.8 LUGARI 60 2007 3.0 NR NR 17 998 1.7 VIHIGA NR NR 520 20092 2.6 750 19811 3.8 TESO NR NR 560 9119 6.1 890 7838 11.4 BUTERE MUMIAS NR NR 223 11628 1.9 55 5427 1.0 TOTALS 451 22844 2.0 3159 121510 2.6 4671 135187 3.5

CENTRAL PROVINCE MURANG'A 103 3530 2.9 204 4346 4.7 380 5058 7.5 THIKA 707 6602 10.7 1618 13887 11.7 449 11154 4.0 KIAMBU NR NR 25 1594 1.6 45 1027 4.4 NYERI 585 NR 1024 NR 938 NR NYANDARUA 192 16828 1.1 223 19709 1.1 357 24431 1.5 MARAGUA 178 6778 2.6 247 8742 2.8 359 7827 4.6 KIRINYAGA 621 16076 3.9 495 12962 3.8 852 14923 5.7 TOTALS 2386 49814 4.8 3836 61240 6.3 3380 64420 5.2

Stunted TOTAL % Stunted TOTAL % Stunted TOTAL % NAIROBI LANG'ATA 119 2133 5.6 EMBAKASI 186 204 91.2 PUMWANI 120 147 81.6 CENTRAL 30 537 5.6 KASARANI 219 3727 5.9 DAGORETI 153 11066 1.4 WESTLANDS 76 2065 3.7 MAKADARA 144 2854 5.0 TOTALS NR NR 324 803 1047 22733 4.6

Annual Report 2003 - 2004 33 Table 29: Malnutrition cases by district from 2002 to 2004 2002 2003 2004 District Malnutrition New % Malnutrition New % Malnutrition New % cases Attendants cases Attendants cases Attendants KISUMU 1152 17177 7% 2413 33627 7% 1517 21340 7% SIAYA 274 2736 10% 1028 6785 15% 888 5803 15% BONDO 930 6100 15% 144 2810 5% 357 4502 8% KISII 692 12506 6% 557 11917 5% 471 16983 3% NYAMIRA 392 4954 8% 1860 5292 35% 1045 6938 15% GUCHA 1668 18834 9% 3161 16475 19% 577 14926 4% RACHUONYO 1197 11403 10% 654 10254 6% 453 4268 11% HOMABAY 705 9998 7% 1037 11775 9% 771 8547 9% NYANDO NR NR NR 681 5752 12% 1100 13946 8% SUBA 425 2771 15% 431 3361 13% 178 1755 10% MIGORI 1297 7020 18% 1643 12695 13% 207 2053 10% SUB-TOTAL 8732 93499 9% 13609 120743 11% 7564 101061 7% EMBU 709 8493 8% 351 20624 2% 691 7386 9% MERU CENTRAL 219 7900 3% 156 8081 2% 1631 9024 18% MAKUENI 1121 14458 8% 1464 75961 2% 1361 14492 9% MWINGI NR NR NR 245 5314 5% 240 3801 6% KITUI 665 4350 15% 1625 19881 8% 502 8873 6% MACHAKOS 646 17658 4% 799 19927 4% 3708 16394 23% MERU SOUTH 220 3064 7% 345 6852 5% 291 5764 5% MERU NORTH 810 15376 5% 688 7810 9% 1312 23082 6% SUB-TOTAL 4390 71299 6% 5673 164450 3% 9736 88816 11% GARISSA NR NR NR NR NR NR 1036 984** IJARA NR NR NR NR NR NR 1374 NR** WAJIR NR NR NR 55 544 10% 56 327 17% SUB-TOTAL 0 0 0 55 544 10% 2466 1311 17% MOMBASA 338 5634 6% 292 3994 7% NR NR NR KWALE 2169 7609 29% 3207 27406 12% 2187 9335 23% KILIFI 3034 24313 12% 2758 21965 13% 1873 14898 13% MALINDI 3712 9293 40% 2244 37088 6% 1200 7787 15% TANA RIVER 1277 1514 84% 1075 2838 38% 109 393 28% TAITA TAVETA 425 5480 8% 641 5866 11% 1077 8149 13% LAMU NR NR NR 110 1088 10% 59 791 7% SUB-TOTAL 10955 53843 20% 10327 100245 10% 6505 41353 16% NAKURU NR NR 166 3447 5% 1837 10737 17% NANDI NORTH NR NR 73 708 10% 185 4034 5% NANDI SOUTH 995 8979 11% 501 6084 8% 228 4792 5% TRANS NZOIA NR NR NR NR NR NR 153 2548 6% TRANS MARA 5 259 2% 306 3174 10% 108 1297 8% TURKANA 2734 6950 39% 2556 16551 15% 5112 8666 59% WEST POKOT 735 6778 11% 756 7047 11% 535 9696 6%

Annual Report 2003 - 2004 34 2002 2003 2004 District Malnutrition New % Malnutrition New % Malnutrition New % cases Attendants cases Attendants cases Attendants BOMET 195 2828 7% 225 5176 4% 53 967 5% KEIYO 1053 7668 14% 1225 5826 21% 746 5994 12% KAJIADO 272 1288 21% 19 27 70% 102 846 12% KERICHO 49 1936 3% 352 4392 8% 165 2465 7% LAIKIPIA 621 6167 10% 707 6160 11% 1477 8431 18% KOIBATEK 170 2864 6% 270 4905 6% 99 2754 4% NAROK 40 947 4% 113 1850 6% 133 3931 3% BURET 578 10526 5% 692 12647 5% 113 3019 4% BARINGO 88 1432 6% 278 2736 10% 46 929 5% SAMBURU 1895 4724 40% 1330 4038 33% 892 4605 19% UASIN GISHU 193 5419 4% 333 5824 6% 39 923 4% MARAKWET NR NR NR NR NR NR 5 432 1% SUB-TOTAL 9623 68765 14% 9902 90592 11% 12028 77066 16%

BUSIA NR NR NR 1560 31505 5% 3125 39808 8% MT ELGON 310 3632 9% 186 3939 5% 676 6385 11% BUNGOMA NR NR NR 4329 19026 23% 4721 22112 21% VIHIGA NR NR NR 1360 20092 7% 1792 19811 9% KAKAMEGA 782 17205 5% 2065 26201 8% 1620 32808 5% BUTERE MUMIAS NR NR NR 1278 11628 11% 315 5427 6% TESO NR NR NR NR NR NR 1787 7838 23% LUGARI 162 2007 8% NR NR NR NR NR NR SUB-TOTAL 1254 22844 5% 10778 112391 10% 14036 134189 10%

MURANG'A 118 3530 3% 251 4346 6% 466 5058 9% KIAMBU NR NR NR 33 1594 2% 148 1027 14% NYANDARUA NR NR NR 520 19709 3% 711 24431 3% MARAGUA 368 6778 5% 419 8742 5% 609 7827 8% KIRINYAGA 955 16076 6% 702 12962 5% 955 14817 6% SUB -TOTAL 1441 26384 5% 1925 47353 4% 2889 53160 5% NAIROBI NR NR NR 4611 803** ** NR NR NR SUB-TOTAL 0 0 0 4611 803 **% 0 0 0

NATIONAL 36395 336634 11% 56880 637121 9% 55224 496956 11% MALNUTRITION RATE

** New attendants for some months were not reported

Annual Report 2003 - 2004 35 Figure 11: Malnutrition Cases

20000

18000

16000

14000

12000

2002 10000 2003

CASES 2004

8000

6000

4000

2000

0 CENTRAL EASTERN COAST WESTERN NYANZA N /EASTERN R /VALLEY NAIROBI PROVINCES

Figure 12: Malnutrition rate by province 2004

Nairobi 0%

Rift Valley Nyanza 20% 9% Coast 20% Western 12% Central N/Eastern 6% Eastern 20% 13%

Source: Division of Nutrition

Ø N/B This is not a true representative of the country because as shown in the CHANIS data, not all districts in the provinces reported in all the years; hence, we are faced by very low reporting rate.

SUPPLEMENTAL FEEDINGS 2003 Ø Unimix – 88 bags Ø Complementary feeds – 10bags Ø E-Pap – 20kg

Annual Report 2003 - 2004 36 2004 Ø E-Pap– 26 bags of 25kg each.

DISTRIBUTION OF MICRONUTRIENT

2004 Ø 14097 tins (500g) of vitamin A 200,000IU. Ø 2070 tins of vitamin A 100,000IU.

Table 30: Resources Available RESOURCE 2002 2003 2004 Vehicles None None None Motorbikes None None None Bicycles None None None Financial AIE MOH 4,733,628 4,733,628 5,073,479 (operational)

LIST OF DONORS / SUPPORTING AGENCIES AND AREAS SUPPORTED a) UNICEF (2002 – 2004) - Micronutrients -Maternal and Child nutrition. -Nutrition in Emergency. b) WHO (2002 – 2004) -Micronutrients -Maternal child nutrition -Nutrition strategic plan

c) CRS (2004) - Infant feeding - World breastfeeding week celebrations

CONSTRAINTS 1) Inadequate funds for: Ø Capacity building in nutrition. Ø Monitoring and supervisory visits. Ø Production of IEC materials. Ø Procurement of vehicles and equipments e.g. weighing scales. Ø Production of data collection and monitoring tools.

2) Few nutritionists to support implementation and monitoring of district / community activities. 3) A ratio of 1:150,000 population

4) No vehicles, motorbikes or even bicycles procured for nutrition services.

4.2 Child Health Services

Introduction

The Division of Child Health has 3 programs namely;-

1. CDD/ARI/IMCI Programme (0-5 year’s age group). 2. Child Health promotion (0-18 year’s age group). 3. Nutrition Programme (all years)

Annual Report 2003 - 2004 37 4.2.1 Aims of the Division of Child Health

· To ensure growth survival and development of children aged below five years · Health promotion for all children – pre-school and school age including adolescents (up to 18 years) both in school and out of school. · To promote good nutrition for children, expectant and nursing mothers the sick and the general population including elimination of micronutrient deficiency.

CDD/ARI/IMCI PROGRAMME.

The programme aims at controlling the childhood diseases (i.e. pneumonia, malaria, diarrhea, measles, malnutrition, anaemia and HIV) which, causes 70% of deaths in children aged below 5 years. This is achieved through the implementation of the Integrated Management of Childhood Illness (IMCI) strategy. The IMCI strategy has 3 components i. Improvement of the health workers skills. ii. Improvement in the health systems. iii. Improvement in the household and community practices necessary for better childcare. IMCI is implemented through the Division of Child Health in collaboration with other Divisions/Programs, other key

Ministries and Partners in development.

DATA COLLECTED BY THE DIVISION

IMCI implementation at the district and health facility level began in year 2001 with the three piloted districts (Kajiado, Vihiga and Embu). A total of 15 Districts were implementing IMCI by end of 2003 and has so far increased to 26 by October 2004.

Table 31: Districts implementing IMCI by province NO. PROVINCE DISTRICTS 1. Western Vihiga, Bungoma, Kakamega, Busia,Teso 2. Rift Valley Kajiado, Turkana, Nakuru, Koibatek 3. Central Kiambu, Kirinyaga, Thika 4. Eastern Embu, Mbeere 5. Coast Kwale, Mombasa, Malindi, Kilifi 6. Nyanza Homa Bay, Nyando, Migori, Kisumu, Kuria 7. N.Eastern Garissa 8. Nairobi Kibera, Pumwani NB · 34% of districts in the country are implementing IMCI. · Each of the 26 districts has had between 1-4 training courses (case management, facilitation skills and follow- up/supervisory skills). It is practically to note that there are no standard tools/forms to collect the data collected in the facilities in the 26 districts. Efforts are being made to start collecting and ensure that feedback is done frequently.

IMCI TRAINED HEALTH WORKERS

Table 32: Number of clinical health workers trained (accumulated totals)

No Type of training 2003 2004 1 Clinical Health workers trained in Case Management 1057 1,396 2 Facilitators 189 320 3 Clinical Instructors 32 44 4 Supervisory Skills 102 138 5 Followed Up 329 401 6 Course Directors 30 30

Annual Report 2003 - 2004 38 NB · Percentage of clinical Health workers in the country trained in IMCI – 7% The target is to train 60% of all clinical health workers in the country

IMCI MONITORING DATA To monitor the implementation status of IMCI the following information is collected through follow-up and routine support supervision activities § Number of clinical health workers trained in IMCI § Number of health facilities in the districts with IMCI § Pre-service institutions teaching IMCI § Health workers skills in managing sick children (Quality of case management) § Health facilities with essential IMCI drugs § Health facilities with supervisory visits in the last 6 months including observation of case management § Districts with IMCI

CONTROL OF DIARRHOEA DISEASE MONTHLY REPORT (CDD)

The summary is supposed to be forwarded on monthly basis to the Division. The report is able to give summaries of assessments, treatment and outcome of diarrhea cases by age (in months) up to five years but very few facilities report. (The form is now being reviewed to capture under five morbidity and mortality data)

Table 33: IMCI activity matrix

OUT PUT TARGETS ACTIVITY ACHIEVEMENTS RECOMMENDA TION/ COMMENT 1-Number of Health 80% of Health facilities - Conduct IMCI -Improvement of -Scaling up facilities implementing having 60% of health training health workers skills Training to IMCI increased. workers with necessary - Conduct in managing children reach the 2-Capacity built for IMCI skills to manage sick supervision - More Health desired targets implementation children according to facilities with IMCI IMCI guidelines by 2010 Increase the number of 50% health facilities with -Support health -Complete under five -Need to have health facilities with well under five registers facilities to acquire morbidity/mortality under five maintained separate under under five registers data morbidity/ five registers -Conduct supervision -Reports on IMCI mortality data activities -Integration of IMCI in to routine supervision Functional ORT corners Increase the number of -Establishment and Improvement of health facilities with strengthening of Oral health functional ORT corners Rehydration Therapy systems/facility by 40% Corners support -Purchase of basic equipment/Supplies - Capacity for c-IMCI 60% of care takers c-IMCI orientation to Community implementation built provide appropriate home districts component of IMCI -Training guidelines treatment for sick children -Train districts c- provided by 2010 IMCI TOTs -IEC materials provided -Sensitization -Communication strategy Malaria, Pneumonia and meetings produced Diarrhoea - c-IMCI training -60% of care takers know guidelines at least 2 signs for seeking -Develop care immediately by 2010 communication -60% of sick children strategy

Annual Report 2003 - 2004 39 Table 33: IMCI activity matrix

OUT PUT TARGETS ACTIVITY ACHIEVEMENTS RECOMMENDA TION/ COMMENT receive appropriate treatment for Malaria, Pneumonia, Diarrhoea - School children de- 75% of school age Conduct de-worming -Creation of worming activities children regularly de- of school going awareness on de- wormed children worming -Train teachers in de- -Training of TOTs worming -school health policy -Advocate for procurement of single dose de- worming drugs

CONSTRAINTS

1. Procurement was centralized but purchases take too long. 2. Process of approving use of funds for planned activities takes time. 3. Even after use of funds has been approved, the other processes of following imprest, getting vehicle clearance, waste a lot of time and effort of the officers. 4. Planning activities with districts becomes difficult to fit into district schedule because of delays at Afya House. 5. Inadequate supportive resources and capacity i.e. computers, vehicles, training and updates in use of information technology. 6. No standardized data collection and reporting tool for under-five morbidity 7. The existing Health Information System data collection tools and reporting tools are not specific in ages 8. IMCI classifications have not been integrated into the normal Routine Health Management Information Systems. 9. Lack of feedback and reporting from the districts on the IMCI especially CDD data.

WAY FORWARD

1. Decentralization of procurement process and regular auditing of same. 2. Funds to be sent directly to user districts and build their capacities for transparent use and accounting. 3. Get rid of “Chasing” culture in Afya House, proposals, letters, requests/ procurements. These should move without officers being physically there. 4. Facilitate and update personnel on computer and use of information technology. 5. More funding for division of child health 6. More data management equipment e.g. computers and other data Storage devices 7. Capacity building for data management staff 8. Integration of IMCI classifications to normal HMIS tools 9. Supply of under-five registers to health facilities for accurate, Reliable and complete under-five data 10. Collect and report data on less than five morbidity and mortality.

Annual Report 2003 - 2004 40 4.3 Malaria Control Programme

4.3.1 Introduction

The Division of Malaria control was established in the year 2000 as the operational arm of the National Malaria Control Programme at the national level. The Objective of the Division is to reduce the level of malaria infection and consequent death in Kenya by 30% by the year 2006 and to sustain that improved level of control to 2010. To achieve this objective, four main strategic approaches have been used i.e. · Clinical management -Providing effective and prompt treatment; · Management of malaria and anaemia in pregnancy; · Vector control using Insecticide- Treated Nets (ITNs) and other methods; · Epidemic preparedness and response (including indoor residual house-spraying)

Supporting structure · Information, Education and communication (IEC) · Monitoring, evaluation and research.

The four strategic approaches will: · Guarantee all people access to quick and effective treatment, to significantly reduce illness and death from malaria; · Provide malaria prevention measures and treatment to pregnant women; · Ensure use of ITNs by at-risk populations, to significantly reduce rates of disease; · Improve epidemic preparedness and response;

There are two cross-cutting strategies on: · Information, education and communication, to better arm the public with preventive and treatment knowledge; · Monitoring, evaluation and research, to constantly up-grade control strategies; · Mobilization of resources to achieve the proposed targets.

The division of malaria control has a capacity of 26 officers working in various technical groups and involved in implementation of these strategic approaches at different levels in collaboration with other departments. Different activities have been going on in various districts under these strategic approaches in collaboration with other divisions and with support from various development partners as shown in the report

The data for the programme has been derived from the routine surveillance database at DOMC and a baseline survey conducted in six sentinel districts. Two major health facilities were selected from each sentinel district for this activity. The findings generally showed that, Children less than five years of age are more affected compared to the other age groups. The reporting rate is very low and the channel of transmitting data from the districts does not seem to be working. It was recommended that IPT could be an option to consider given that all other efforts like ITNs and home treatment of fevers have been put in place yet these are not making the desired impact of reducing mortalities and morbidity among the under fives.

To assess the overall impact of the national malaria strategy on the health of the community at large, two approaches have been undertaken by DOMC:

1. Facility level · Age-structured, malaria case- fatality rates from the HMIS database from hospital facilities; · Annualized and monthly case burdens presenting as out-patients from HMIS database for dispensaries and health centers; · The proportion of severe malaria admissions to hospital requiring blood transfusion from IDS- sampled facilities; · The proportion of hospital deliveries with a birth weight less than 2500gm (by parity) derived from annual reviews of data at sampled health facilities. · The proportion of women with severe anaemia (Hb < 7 gms/dl) in the third trimester at the time of delivery;

Annual Report 2003 - 2004 41 2. Community level The national census and the Kenya demographic health survey to provide details or sample size to measure the impact on mortality due to acute fever, by age and by malaria ecological zone. The two key impact parameters · All-cause infant and under 5 mortality · Malaria specific mortality among individuals aged <1year, 1-4 years, 5-14 years and adults. Baseline surveys provide most of these data and are carried out annually. Routine data has become very unreliable due to problems at the facility level as well as the central level. As much as information is becoming increasingly important in decision making, a lot is needed in order to improve the quality of data collected in the health facilities.

CASE MANAGEMENT · DOMC revised, printed and distributed 3000 booklets on clinical guidelines for case management by health workers. · IMCI is the strategy adopted for case management and the Division of child health was supported to scale up implementation of IMCI in Nyando district where10 facilitators and 24 supervisors were trained in IMCI. · 15 districts from Nyanza province, Kitui in Eastern, Kirinyaga in Central and Trans Nzoia in Rift Valley were supported and conducted updates for 205 laboratory technicians on malaria microscopy and other diagnostic skills to support the management of malaria cases · The shopkeeper-training programme was expanded from 2 districts to 5 · 26 DHMT members from Makueni, Busia, Kwale, Kilifi, Gucha and Nandi North districts trained these districts were trained as TOTs · The DHMTs were supported to train 92 other health workers especially divisional PHOs as TOTs for the shopkeepers training programme · 54 bicycles were purchased to support the Shopkeeper training programme · 12 districts from Nyanza province, Kitui in Eastern, Kirinyaga in Central and Trans Nzoia in Rift Valley, were supported to implement priority activities from their business plans. · 1222 CHWs trained/oriented on case management. · 1408 Shopkeepers were trained on good drug dispensing practices. · 26 BI TOTs, 350 teachers, 260 Chiefs, Beach and other opinion leaders were oriented on malaria control activities

4.3.2 Trainings

Table 34: Shopkeeper (IMCI) Province (2003) No. Of H/Workers Topic Job aid Trained Distributed COAST (Kwale) 5 Home based malaria management WESTERN (Busia) 4 Home based malaria management EASTERN (Makueni) 6 Home based malaria management RIFT VALLEY (N.Nandi) 2 Home based malaria management NYANZA (Gucha) 4 Home based malaria management TOTAL 21 2004 NYANZA 27 Home based malaria management 2400 Job Aids WESTERN 33 Home based malaria management 1600 Job Aids RIFT VALLEY 31 Home based malaria management 2000 Job Aids TOTAL 91 91 manager guide for shopkeeper training

4.3.3 Management of malaria and anaemia in pregnancy DRH supported (by WHO) to · Conduct a meeting for specialists on improving services on quality of maternal services. · Test protocol guidelines on quality obstetric and pre-natal care. · Indicators for malaria in pregnancy are not captured during routine data collection. A joint study by WHO, DOMC and DRH was conducted in two districts (Busia and Kilifi to test use of tools for indicators of malaria in pregnancy.

Annual Report 2003 - 2004 42 Table 35: Focused Antenatal Care and Malaria in Pregnancy (FANC/MIP) Province No. Of Health No. Of Health Topic Job Aid Distributed Workers Trained Workers Trained 2003 2004

COAST 45 54 Focused Antenatal Care N.EASTERN 5 5 Focused Antenatal Care NYANZA 25 30 Focused Antenatal Care R.VALLEY 20 24 Focused Antenatal Care EASTERN 45 54 Focused Antenatal Care WESTERN 35 42 Focused Antenatal Care TOTAL 95 209 Focused Antenatal Care

· Inventory for medical laboratories in Nyanza province done · Strategies worked out on utilization of Global funds by NGOs · Malaria symposium held during the 13th AKMLSO medical laboratory scientific conference. · Establishment of a country collaboration centre for MEWs is ongoing. · Developed Integrated Plan of Actions (IPOAs) malaria component for 11 districts from Rift Valley Province.

4.3.4 Vector control using insecticide- treated nets and other methods

IRS/ ITNs · DOMC Supported by WHO with 52,000 ITNs and 25,000 deltamethrin net re-treatment kits for free distribution to the vulnerable groups through: Peripheral health facilities · CBOs/OCGs at Constituency level using MPs. · The initial districts supported to implement IVM were supported to expand the activities to other divisions in the district. · Additional districts - Kirinyaga, Homa Bay and Kwale, were included in the scaling up of IVM through mass net re- treatment activity. · DOMC supported by WHO to hold ITN technical working group meetings that reviewed the process to develop ITN strategy and other non-technical ITN issues.

Table 36: Distribution of ITNS and IRS Materials

YR 2003 2004 PROVINCE/I ITNs SPRAYING RETREATMENT (Icon) (K-Othrine) TEM PUMPS KITS Nyanza 4884 2600 R.Valley 13912 6600 Western 3552 1800 Eastern 296 200 TOTAL 280,000 169 270,000 22644 Sachets 11200 Sachets

4.3.5 Epidemic preparedness and response · The 6 key divisions supported 10 additional districts in Rift Valley Province - Bomet, Bureti, Kericho, Nandi North, Nandi South, Koibatek, Uasin Gishu, Trans Nzoia, West Pokot, Baringo to develop their business plans; · 10 additional epidemic prone districts were supported with computers to enhance their capacity in data management; · A workshop on Malaria Early Warning System (MEWS) was held for the 14 highland epidemic prone districts where districts were given feedback on the analysed data collected from 2 epidemic detection sites;

· Using weekly data from their health facilities districts were assisted to calculate the epidemic thresholds for their local areas; · DOMC was supported and conducted a rapid assessment on the malaria situation early in the year to determine the potential for an epidemic outbreak in western highlands. Findings indicated low potential of an epidemic in the region. However, the general trend of malaria morbidity is on the increase;

Annual Report 2003 - 2004 43 · Technical support was provided to DOMC to establish malaria database and included training of data managers from DRH, DOMC, EPI, IDSR, and HMIS on use of statistical computer packages (Ms Access, Epi Info and SPSS). A Visit was made to Kirinyaga to review the districts experience with health data generation and utilization; · DOMC and DEH were supported and established community spray teams for IRS at household level in 15 highland epidemic prone districts; · Training of 30 TOTs, 210 supervisors and 1550 spray men; · Formation of teams and actual spraying; · Mapping of high-risk areas; · The MOH continued the establishment of community spray teams in the 14 districts and based on district demands for commodities WHO supported the districts with additional 437 stainless steel spray pumps and 7,500 sachets of chemicals for IRS; · At the start of the year the Western part of the country experienced heavy rains that caused floods in some districts. 100,000 vials of I.M/I.V Quinine, 200,000 tablets of SP were procured for the flood-affected districts; · During the RD’s visit to Kirinyaga district it was identified that the districts needed oxygen extractor machines for paediatric cases and WHO supported it with 2 units; · The capacity to forecast malaria epidemics is not yet established in the country. The MOH will have to rely on monitoring malaria trends in the epidemic prone districts using the weekly data collected from the facilities. With the extension of data collection to peripheral health units using the threshold charts it has become possible to detect early upsurge in malaria cases and based on the prevailing climatic conditions the last 2 months it is possible to predict a serious upsurge breaking through to epidemic proportions. This makes it easier for the DOMC to inform districts and partners with a degree of certainty of a pending possible emergency;

Table 37: Makueni district malaria data

1 2 3 4 5 6 7 Q1 Median Q3 2003 2004 2005 JANUARY 13428 14994 16491 18387 20351 21670 21714 23480 17340 24235 FEBRUARY 15116 18073 18414 18808 19485 31831 33298 24249 21178 27594 MARCH 11763 14781 15622 15683 24332 29482 49244 22292 23911 APRIL 13900 16308 16774 17764 18121 18530 32536 14269 16862 MAY 14017 16503 18095 19555 24581 25264 25942 16279 24398 JUNE 15261 16196 17059 17412 22798 24091 27453 21257 19575 JULY 13365 15784 16491 17751 20491 24154 26762 21181 24125 AUGUST 11168 12174 14142 14534 15868 19340 20046 10684 18212 SEPTEMBER 9116 9684 10289 11620 13858 14138 14139 10652 15518 OCTOBER 9147 10326 10765 11123 11447 12790 12947 11905 13311 NOVEMBER 8488 8603 9248 9328 10264 10463 11137 8772 22003 DECEMBER 7740 8965 9658 10489 10538 11251 11486 11829 18185

Figure 13: Makueni District Malaria Threshold

Annual Report 2003 - 2004 44 4.3.6 Information, Education and Communication

With support from WHO · Around the commemoration time of the AMD, IEC materials were printed · On Case management,22,100 leaflets on management of fever · 10,000 brochures on malaria control and prevention measures · 10,000 sun visors with malaria control messages · 2 PVC banners on Africa Malaria Day (AMD) were hoisted at the venue for AMD commemoration · Vector control · 3,000 posters on the AMD theme

Shopkeeper programme · 100,000 leaflets, 500 flip charts, 5,000 posters, 5,000 booklets (A5) and 2,000 booklets (A4) to support shopkeeper /retailer programme. · Printed 8,000 copies of the NMS booklets

ITN promotion · 4,810 English and 14,250 Kiswahili posters on ITN promotion were distributed to districts for dissemination.

IRS activities · 10,000 posters, 40,000 brochures on malaria control activities were distributed at village level during the implementation of IRS activities in epidemic prone districts. · NMS booklets Distributed 8,000 copies to districts and conferences/ workshops/seminars · 3 DOMC staff attended short courses in communication skills; · MOH in collaboration with drug, chemical and net manufactures disseminated messages on malaria control and prevention measures the print media in for of Newspaper supplements and advertisements. · Filming of community based malaria control activities for worldwide documentation was done in the district with best practices in malaria control ; · Districts were supported to conduct sensitisation campaigns in malaria control · Nyanza province supported to conduct advocacy and community sensitisation meetings. · During the 13th AKMLSO medical laboratory scientific conference the association was supported to host a symposium on malaria. The DOMC used the opportunity to disseminate the NMS and current approaches in malaria control to this cadre of staff. · MOH was supported to host a Public Health Day in Trans Nzoia on the ‘Health Villages Initiative’ for partners to see the district with the best practices in community based health issues · Supported video documentation of malaria control activities in Kenya targeting: o Health Villages Initiative in Trans Nzoia district, Bamako Initiatives in Kirinyaga district and Research in malaria at KEMRI · MOH supported 40 districts and 6 Provinces to organise the weeklong activities to commemorate the AMD. · WHO supported 28 districts to commemorate the AMD. Commemoration of the AMD was used: o To launch the 1st Africa Malaria Progress Report ; o As an opportunity for global partners to meet with local partners and share experiences in progress in malaria control issues · Regional Director visited community based malaria control activities in Kirinyaga district where he pledged support to the district including USD 10,000 to scale up malaria control activities, hospital theatre equipment, a vehicle and extension for Kimbimbi sub district hospital.

Table 38: Summary of IEC materials distributed in 2003 District Manager’s guide Flip charts SK Booklets Shop Posters Information leaflets Kwale 10 15 200 200 25,000 Kilifi 10 10 100 100 5,000 Makueni 10 25 500 500 20,000 Busia 10 10 100 100 15,000 Nandi 10 12 300 300 18,000 Gucha 8 12 120 120 15,000 Total 58 84 1320 1320 98,000

Annual Report 2003 - 2004 45 4.3.7 Monitoring, Evaluation and Research. · The provincial teams were supported to train the district managers in supervisory skills and the districts supported to conduct supervisory activities within their health institutions; · Nyanza province and Kirinyaga district were supported and trained 106 DHMT members in supervisory skills. 15 districts were supported and the trained managers undertook supervisory visits to health facilities; · 3 (three) 4 WD double-cabin pick up vehicles were purchased for Kirinyaga, Kitui and West Pokot districts to ease transport problems in the districts; · Facility based survey on quality of health services being provided by health facilities done in six sentinel sites (Busia, Bondo, Kisii, Kirinyaga, Kwale, Makueni); · DOMC supported and conducted drug sensitivity testing through EANMAT on 1st and 2nd line anti-malarial drugs in two sentinel sites Makueni and Bondo; · DOMC supported and updated EANMAT staff on procedures for conducting Combination Therapy activities to enhance CT studies in Makueni and Bondo. · NPHLS and DOMC were supported and conducted an inventory on quality of laboratory services provided in health institutions in districts of Nyanza province; · DOMC was supported with an additional 4x4 WD multipurpose pick-up to improve on monitoring activities in districts especially the 15 that were given support to implement malaria control measures · A WHO/AFRO consultant was supported for four months and assisted DOMC and 15 districts in identification of priority activities in their business plans that were funded · KEMRI/WELCOME Trust supported and conducted community surveys on the role of the drug retailer in case management. · Therapeutic efficacy tests have been going on in three sites namely Chulaimbo, Nandi North and Gucha with support from WHO/DFID.

4.3.8 Malaria surveillance

This section displays a summary of the data collected routinely from the districts and the results of the baseline survey carried out in three sentinel districts. The data are presented in tables and graphs and shows the cases less than five years and pregnant women. The data excludes the male adults.

Annual Report 2003 - 2004 46 Table 39: Malaria Sentinel crude data reported by districts in the year 2003

DISTRICT JAN FEB MAR APRIL MAY JUNE JULY AUG SEPT OCT NOV DEC TOTAL Trans Nzoia 13702 15408 17797 13482 13865 15370 25715 16466 13374 12162 9572 10513 177426 Nandi South 1198 14446 14778 12902 13558 16168 14977 15053 11855 11163 10759 10495 147352 Nandi north 11836 15132 13843 8878 9797 11850 40402 8232 3256 2787 2339 2586 130938 Kericho 9833 10818 11339 7030 6696 14888 18712 8285 5706 6716 4237 5196 109456 Uasin Gishu 15203 14923 16055 14221 15048 16881 16714 15098 10034 7373 6196 7080 154826 W/Pokot 6514 7028 6765 4988 5448 9648 18454 13533 15969 12114 6159 5077 111697 Bomet 4342 9036 11724 5608 5448 4615 9777 7588 4384 4181 3335 3174 73212 Kisii 18564 22567 15768 11718 11882 13702 20873 9632 8751 7605 5977 7323 154362 Nyamira 25312 26945 20705 14711 17098 20378 38700 18985 19052 11772 11849 13147 238654 Kitui 20882 27853 23632 16978 16821 20479 19646 11534 11788 10180 0 0 179793 Bungoma 9241 12444 13450 10891 13019 13918 18009 14380 11841 14346 0 0 131539 Keiyo 2381 2657 2718 2098 2367 3366 7255 3609 4439 0 1526 1732 34148 Gucha 18368 17933 10698 6968 7660 8720 19250 9685 7150 6523 5956 6307 125218 T/Mara 6491 9103 8362 4713 4648 4543 5235 3848 3939 4027 3289 2236 60434 Makueni 23480 24249 22292 14269 16279 21257 21181 10684 10652 11905 8772 11829 196849 Total 187347 230542 209926 149455 159634 195783 294900 166612 142190 122854 79966 86695 2025904

Annual Report 2003 - 2004 47 Figure 14: Malaria trends for the year 2003 in 14 districts

TOTAL SENTINEL MALARIA DATA 2003

DEC 86695

NOV 79966

OCT 122854

SEPT 142190

AUG 166612 MONTH JULY 294900 Total JUNE 195783

MAY 159634

APRIL 149455

MAR 209926

FEB 230542

JAN 187347

0 50000 100000 150000 200000 250000 300000 350000 REPORTED CASES

The cases started going up in April reaching a peak in July as the chart indicates. In August the cases dropped drastically and kept on dropping but then started going up again in December.

Figure 15: Malaria trends in 5 epidemic prone districts in 2003

140000 Sharp rise 120000

100000

80000

60000 No. of mal cases mal of No. 40000

20000

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Months

Trans Nzoia Nandi South Nandi north Kericho Uasin Gishu

It is clear from the graph that malaria cases started going up in the month of January to march after the short rains in December and then stabilized in the months of April and May shooting up sharply in July especially in Nandi North,Trans Nzoia and Kericho after the long rains in April. A sharp decline is noted in Nandi North in the month of August and remained stable up to December.

Annual Report 2003 - 2004 48 Figure 16: Malaria trends in 10 districts in 2003 Highest 200000 peak

180000

160000 Rain 140000 season 120000

100000

80000

60000 No. of mal cases per districtper cases mal of No. 40000

20000

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Months

W/Pokot Bomet Kis ii Nyamira Kitui Bungoma Keiyo Gucha T/Mara Makueni

There was a marked increment in the number of cases in all the districts from January to February which stabilized in April. All the districts experienced a more sharp increment of malaria cases from June reaching a peak in July and started to decline in September with another rise noted in December.

Annual Report 2003 - 2004 49 Table 40: Summary of Sentinel Surveillance Data by district Month Data Trans Mara Kericho Buret West Pokot Bondo Nandi South Nyamira TOTAL January Pregnant 196 136 137 44 768 1 3328 4610 < 5 years 2619 2385 1922 809 1209 175 8461 17580 > 5 years 4060 5466 4324 763 254 667 136 15670 February Pregnant 223 116 160 89 510 31 4255 5384 < 5 years 4770 2861 2229 1196 758 674 10630 23118 > 5 years 7767 6865 6120 1275 190 1690 257 24164 March Pregnant 190 105 176 29 501 253 2914 4168 < 5 years 3310 2490 2127 682 810 1835 6865 18119 > 5 years 5143 5223 4635 737 181 3849 156 19924 April Pregnant 259 84 83 76 433 126 2299 3360 < 5 years 1894 1414 1024 961 593 1506 5268 12660 > 5 years 2529 3067 2414 928 181 2852 136 12107 May Pregnant 89 70 142 62 365 146 2475 3349 < 5 years 1489 1019 925 960 530 1617 6484 13024 > 5 years 2584 2731 2437 849 84 3665 99 12449 June Pregnant 48 149 114 81 628 207 2794 4021 < 5 years 1523 2138 802 1906 843 2073 7435 16720 > 5 years 2412 4983 2645 1817 162 3365 155 15539 July Pregnant 46 85 210 81 441 56 4960 5879 < 5 years 714 3491 1986 2179 861 1045 13421 23697 > 5 years 1184 8208 4354 2557 166 1890 195 18554 August Pregnant 80 69 44 184 908 2479 3764 < 5 years 1182 1296 547 3458 1204 6626 14313 > 5 years 1961 2486 1317 4258 194 113 10329 September Pregnant 97 33 21 270 640 60 1175 2296 Pregnant 1011 553 459 2695 873 655 3312 9558 < 5 years 1691 1339 1247 2863 148 2134 112 9534 October > 5 years 10 8 24 93 575 27 423 1160 Pregnant 93 126 473 1896 869 530 921 4908 < 5 years 131 421 1221 2096 157 1388 65 5479 November > 5 years 8 2 101 330 89 86 616

Annual Report 2003 - 2004 50 Month Data Trans Mara Kericho Buret West Pokot Bondo Nandi South Nyamira TOTAL Pregnant 92 98 1446 551 1920 196 4303 < 5 years 120 191 1494 98 3466 28 5397 December > 5 years 107 3 42 549 14 715 Pregnant 1055 8 906 739 243 2951 Pregnant 1618 24 676 119 488 2925 Total cases Pregnant 1353 855 1116 1152 6648 1010 27188 39322 Total cases < 5 years 19752 17773 12600 19094 6649 12273 69619 157760 Total cases > 5 years 31200 40789 30929 20313 1934 25454 1452 152071 Total Population 196,198 538,874 369,504 354,356 261,781 664,298 546,090 2931101 Disease Burden 266.6/1000 110.3/1000 120.8/1000 144.5/1000 58 /1000 58.3 /1000 180/1000 0

Annual Report 2003 - 2004 51 The reporting rate was quite low in all the districts. The best reporting district was Bondo with a mean reporting rate of 63.2%, followed by Bureti with a mean rate of 60%, Bomet with 56.9%, Trans Mara with 51%, Nyamira with 45.1%, West Pokot with 41.7%, Nandi South with 34.2% and the lowest was Kisii with 16.7%

Transmara district has the highest disease burden of 267 cases per 1000 population while Bondo district had the lowesr with 58 people per 1000 population.

Table 41: Summary of malaria cases in 6 reporting districts

DISTRICT AGE GROUP % of pop % of % of % of <5 pop >5 Pregnant estimated TOTAL Total <5 5& Above women pregnant pop BURETI 12600 16.63 30929 10.35 1116 5.62 44645 12.08 NANDI S. 12273 10.71 25454 4.72 1010 2.92 38737 5.83 KERICHO 17773 19.35 40789 9.32 855 2.95 59417 11.02 T. MARA 19752 49.88 31200 20.43 1353 12.37 52305 26.65 W.POKOT 19094 27.01 20313 7.33 1152 5.96 40559 11.44 BONDO 6648 15.01 6649 18.19 1934 13.01 15231 5.9

N.B 2003 population projection used

Figure 17: Number of Malaria cases by age in 5 epidemic prone districts.

No. of malaria cases by age in 5 sentinel sites

45000 40000 35000 30000 <5 25000 5& Above 20000 Pregnant women

No. of cases 15000 10000 5000 0

BURETI T. MARA NANDI S. KERICHO W.POKOT District

The graph indicates that Kericho had the highest number of malaria cases among children aged 5 years and above while Trans Mara had the highest number of cases among children under 5 years followed by Bureti and Nandi south respectively which are all epidemic prone districts.

Figure 18: Estimated percentage of sick population in 5 sentinel districts

Annual Report 2003 - 2004 52 60

50

40

30

20 Estimated % of sick pop % of sick Estimated 10

0 BURETI NANDI S. KERICHO T. MARA W.POKOT DISTRICTS

% of sick pop <5 % of sick pop >5 % of sick preg women

The number of cases among U5s was high in some districts such as Trans Mara and West Pokot that are epidemic prone as can be seen from the chart above. Part of West Pokot is highly epidemic. Nandi South shows low number of cases because half of the district is endemic. The number of cases among pregnant women remained stable throughout the year.

Research Therapeutic efficacy tests have been carried out by East Africa Network for monitoring Anti-malarial Therapy in collaboration with DOMC and other development partners over a period of 5 years and more are still going on in three sentinel districts .Below are the outcomes of these tests.

Randomized control trials have been carried out by East Africa Network for monitoring Antimalaria treatment for more than three years and below are the outcomes. More tests are going on. ACPR- Adequate clinical and parasitological response LCF-Late clinical failure ETF- Early treatment failure LPF- Late parasitological failure

N.B: Drug distribution done by KEMSA. While Donations received are distributed to most deserving areas. Table 42: Outcome of a malaria drug efficancy Count of RECFORM OUTCOME2 Grand STUDY SITE YEAR TESTDRUG ACPR ETF LCF LPF Total BONDO 1999 AQ 46 46 2000 AQ 59 59 SP 40 10 6 4 60 BUSIA 1999 AQ 34 1 4 39 CQ 14 2 26 2 44 SP 40 3 1 44 2000 AQ 59 1 60 SP 42 2 2 11 57 2001 AQ 57 2 2 61 SP 46 1 4 6 57 KIBWEZI 2000 AQ 13 1 14

Annual Report 2003 - 2004 53 Count of RECFORM OUTCOME2 Grand STUDY SITE YEAR TESTDRUG ACPR ETF LCF LPF Total SP 9 1 1 11 2001 AQ 22 3 25 SP 14 2 1 2 19 2002 AQ 33 1 34 SP 14 5 10 2 31 KIRINYAGA 1999 AQ 20 4 1 25 SP 32 2 5 39 2000 AQ 56 1 4 61 SP 36 4 7 12 59 2001 AQ 28 3 6 37 SP 16 4 8 5 33 KISUMU 1999 SP 32 4 36 2000 AQ 50 4 1 55 SP 36 10 15 4 65 2002 AQ 53 1 54 SP 49 2 8 59 2000A AQ 20 3 3 26 KWALE 2000 AQ 63 1 64 SP 61 2 63 2001 AQ 57 57 SP 46 3 1 3 53 LAMU 2000 AQ 35 1 36 SP 42 1 43 NANDI 2001 AQ 19 19 SP 14 2 1 2 19 Grand Total 1307 55 119 83 1564 Count of RECFORM OUTCOME2 Grand STUDYSITE YEAR TESTDRUG ACPR ETF LCF LPF Total BONDO 1999 AQ 100.00% 0.00% 0.00% 0.00% 100.00% 2000 AQ 100.00% 0.00% 0.00% 0.00% 100.00% SP 66.67% 16.67% 10.00% 6.67% 100.00% BUSIA 1999 AQ 87.18% 2.56% 10.26% 0.00% 100.00% CQ 31.82% 4.55% 59.09% 4.55% 100.00% SP 90.91% 6.82% 0.00% 2.27% 100.00% 2000 AQ 98.33% 0.00% 0.00% 1.67% 100.00% SP 73.68% 3.51% 3.51% 19.30% 100.00% 2001 AQ 93.44% 0.00% 3.28% 3.28% 100.00% SP 80.70% 1.75% 7.02% 10.53% 100.00% KIBWEZI 2000 AQ 92.86% 0.00% 7.14% 0.00% 100.00% SP 81.82% 9.09% 9.09% 0.00% 100.00% 2001 AQ 88.00% 0.00% 12.00% 0.00% 100.00% SP 73.68% 10.53% 5.26% 10.53% 100.00% 2002 AQ 97.06% 0.00% 0.00% 2.94% 100.00% SP 45.16% 16.13% 32.26% 6.45% 100.00% KIRINYAGA 1999 AQ 80.00% 0.00% 16.00% 4.00% 100.00% SP 82.05% 5.13% 12.82% 0.00% 100.00% 2000 AQ 91.80% 0.00% 1.64% 6.56% 100.00%

Annual Report 2003 - 2004 54 Count of RECFORM OUTCOME2 Grand STUDY SITE YEAR TESTDRUG ACPR ETF LCF LPF Total SP 61.02% 6.78% 11.86% 20.34% 100.00% 2001 AQ 75.68% 0.00% 8.11% 16.22% 100.00% SP 48.48% 12.12% 24.24% 15.15% 100.00% KISUMU 1999 SP 88.89% 0.00% 11.11% 0.00% 100.00% 2000 AQ 90.91% 0.00% 7.27% 1.82% 100.00% SP 55.38% 15.38% 23.08% 6.15% 100.00% 2002 AQ 98.15% 0.00% 0.00% 1.85% 100.00% SP 83.05% 0.00% 3.39% 13.56% 100.00% 2000A AQ 76.92% 11.54% 11.54% 0.00% 100.00% KWALE 2000 AQ 98.44% 0.00% 0.00% 1.56% 100.00% SP 96.83% 0.00% 0.00% 3.17% 100.00% 2001 AQ 100.00% 0.00% 0.00% 0.00% 100.00% SP 86.79% 5.66% 1.89% 5.66% 100.00% LAMU 2000 AQ 97.22% 0.00% 2.78% 0.00% 100.00% SP 97.67% 0.00% 0.00% 2.33% 100.00% NANDI 2001 AQ 100.00% 0.00% 0.00% 0.00% 100.00% SP 73.68% 10.53% 5.26% 10.53% 100.00% Grand Total 83.57% 3.52% 7.61% 5.31% 100.00%

General comments and research findings;

· The reporting rate is very low and the channel of transmission seems not to be working. · No district has been able to send its reports on time so timeliness was at 0%.Completeness of reports was not a problem to the districts because all reports were well completed by the Respective districts; · There is no coordination of activities at DOMC to ensure that every activity carried out is compiled at one point; · Case Fatality Rate is high among children under 5 (11/480) compared to other age groups (5/262) among the 5- 14yrs age group in Bondo; · The disease burden is heavier on children under 5 at 79.5% and 65.98 % in Bondo and Busia respectively; · In Bondo district hospital, 79.5% of all admissions of children under 1 year were due to malaria while 37.7 % of all admissions of 15yrs+ were due to malaria; · A higher number of stillbirths were noted among the primigravidas in Busia district while there were a higher number of abortions among multigravidas in the same health facility. The situation was similar in Bondo district hospital and Abidha health centre; · In Abidha health centre 98% of all admissions were due to malaria among all age groups; · The number of out-patient malaria cases was higher among the under fives (1688) as compared to 5-14 years (487) in Abidha health centre; · In Busia district hospital 63.6% of all admissions were due to malaria among the under fives and 48% among other age groups.

Recommendations · The channel of transmission of data should be reviewed with an aim of improving the flow of data to the central level; · Integration of different programmes should be encouraged to reduce the workload (too many data collection tools) on the district Health Records and Information Officers and also to make good use of the scarce resources in the districts e.g. computers.; · Review meetings with the districts should be held regularly to facilitate feed back and dissemination of information and also to discuss any abnormal trends;

Annual Report 2003 - 2004 55 · More support should be given to the districts (e.g. Motor bikes) to enable them reach the remote health facilities to collect reports/data; · Regular support supervision visits should be made to the districts in order to correct any noted anomalies instead of trying to solve problems at the end of the year; · It is particularly interesting to note that abortions are higher among the multigravidae than the primigravidae (see Tables above) while it has been thought that primigravidae would suffer higher numbers of abortions. Further studies could be done to ascertain the cause of this finding given that these mothers have already undergone some education and orientation on how to reduce the incidence of abortions; · Greater efforts must be made to ensure that measures aimed at reducing malaria incidences among the under fives are put in place; · IPT could be an option to consider given that all other efforts like ITNS and home treatment of fevers have been put in place yet these are not making the desired impact of reducing mortalities and morbidity among under fives; · Greater emphasis must be put on measures aimed at increasing birth weights among pregnant women, IPT and use of ITNs should be emphasised both in terms of making them more accessible by using CORPs for the distribution of the same and also greater education using community leaders, TBAs etc; · Community involvement in bettering the health of it’s own people could be an option to consider, this will enable programs like education and awareness on the disease, causes, measures that can be put in place for prevention, home management of fevers and net distribution and re-treatment. This will reduce the burden of the health worker at the hospital hence better quality of healthcare will be availed by him/her; · The issue of poverty still remains a problem in terms of access to healthcare, if communities are empowered to generate their own income to purchase nets collectively, greater impact on the disease burden will be achieved; · Data collection could also be done by TBAs these should undergo training on how to improve the pregnancy outcomes and how they can collect data on the same, this will give a better picture of what is on the ground since a greater percentage of Kenyans self treat at home and many women have home deliveries especially in the rural areas. If TBAs can be educated and trained, better results will be achieved; · More emphasis to be put on records keeping in both the district hospitals and the Mission hospitals to make the exercise easier in future; · Delivery registers to be reviewed with an aim of capturing more data from these units and making work easier for the nursing staff;

Challenges · Poor reporting rate by districts. · Poor records keeping in the main hospitals which made the work take a longer period than expected. · Unavailability of records in the mission hospitals in some hospital. · Few Health Records & Information Officers in the district hospitals with a heavy workload hence limited assistance to the team. · The use of hand drawn Delivery registers in some hospitals making it hard to include all the information needed like the weight of the baby. · It was not possible to collect data from all the health facilities in the district due to inadequate resource materials and time, as well as inappropriate record keeping in some of the health facilities such as Kisii and Gucha.

RESOURCES AVAILABLE § 20 personal computers § 9 HP small laser printer § 2 HP heavy duty printer § 2 HP colour printer § 2 HP flatbed scanner § 5 Lap Tops § 2 Iomega zip drives § Purchased two 4x4 double cabin Toyota vehicles § Procured 100,000 vials of I.M/I.V Quinine 600ml/2ml § Procured 54 bicycles to support the Shopkeeper training programme Supported Kirinyaga district with 2 oxygen extractor machines Supported 13 districts with personal computers.

Annual Report 2003 - 2004 56 SUPPORTING AGENCIES – (Offers both technical and financial support)

WHO DFID GOK GFTAM UNICEF

CONSTRAINTS · Low allocation from GOK · Inconsistent support to districts from GOK resources . · Getting data from field on time

WAY FORWARD FOR DOMC · Increased budget allocation by GoK to the division · Consistent support to districts · Streamline data transmission from districts to central level

4.4 Disease Outbreak Management Unit (Domu). Disease Outbreak Management Unit (DOMU) was established within the Division of Communicable and Vector Bone Diseases (DCVBD) by the ministry of Health in 1999. The objective was to strengthen surveillance for action for priority communicable diseases and coordinate more efficiently epidemic preparedness and response. These was to be established at all levels of health care system i.e. Central, Provincial and district levels. At the central level, DOMU secretariat is strengthened with technical staff such as an epidemiologist, public health nurse, two public heath officers, two clinical officers, two medical laboratory technologists, two health records and officers and a pharmaceutical technologist.

Reporting On Communicable Diseases Epidemic data management is one of the core pillars of Integrated Disease Surveillance and Response (IDSR). The other pillars are Laboratory, Epidemic preparedness and response, Training and Communication. IDSR handles only 18 priority communicable diseases which are classified as follows:- Epidemic prone diseases; Cholera, Diarrhoea with blood (Dysentery), Meningitis (Epidemic), Typhoid fever, Plague, Viral Hemorrhagic Fever (VHF), and Yellow Fever Diseases targeted for eradication and elimination; AFP, Measles, Leprosy, NNT and Guinea worm Other diseases of public health importance; Diarrhoea in under five years, Pneumonia in under five years, New Aids cases, Tuberculosis, Malaria, and STIs

IDSR reporting formats: The 18 priority communicable diseases are reported in the following formats; Immediate (Case Base) reporting. AFP, NNT, Measles, Meningococcal Meningitis, Plague, VHF, Yellow Fever Routine reporting Cholera, Typhoid fever, Dysentery, Measles, Meningococcal Meningitis, Plague, Yellow fever, and Other VHFs Diseases reported weekly (epidemic prone diseases) Weekly, Monthly and Quarterly Monthly Out/In patient reporting. Malaria, Pneumonia in under five years, Diarrhoea in under five years, New AIDS Cases, STIs, Diarrhoea with blood Quarterly reporting Tuberculosis, and Leprosy,

4.4.1 Communicable diseases reported in 2002, 2003 and 2004.

In 2002 there was a cholera outbreak in Kwale and Mombasa districts. It started in the second quarter and was controlled in the third quarter. A total of 319 cases were recorded in the two districts and ten deaths were reported with a CFR of 3.1%. In 2003 none of the district reported any cholera case. This has not been the case for over ten years. However, Tana River, Taita Taveta districts reported 24 measles cases, Malindi and Tana-River also reported 295 Typhoid cases and 330 cases of Dysentery were reported in Tana River and Malindi districts. A few districts reported monthly data on malaria and were

Annual Report 2003 - 2004 57 assisted to establish their malaria thresholds. 2004 had several disease outbreaks reported in almost all quarters of the year. The following is a summary of the diseases reported, cases, deaths and the districts affected.

The cases were as shown in table 37 below;

Table 43: Disease Outbreaks Reported Disease Cases Deaths CFR% Districts affected 1 Cholera 392 7 1.8 Kwale, Kilifi, Mombasa, Taita Taveta, Makueni and Nairobi. 2 Diarrhoea 170 0 0 Kitui and Malindi 3 Typhoid 27 0 0 Kitui and Malindi 4 Influenza 5 0 0 Kiambu 5 Aflatoxicosis 270 99 36.6 Makueni, Kitui, Machakos, Embu, Mbeere, and Thika 6 Leptospirosis 854 12 1.4 Bungoma and Mt Elgon Figure 19: Cholera Outbreak in Kwale, 2002

100

80

60

40 CASES

20

0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 123456789 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

CASES 00000000000000000000001339228771094741200000000000000000000 WEEKS CASES

Table 44: Cholera Trends 1979 - 2004

Year Cases Deaths CFR % 1979 1082 2 0.2 1980 3863 61 1.6 1981 9403 0 0 1982 5327 0 0 1983 2172 75 3.5 1998 15364 923 6 1999 10964 368 3.4 2000 1509 93 6.2 2001 1001 55 5.5 2002 319 10 3.9 2003 0 0 0 2004 392 7 1.8

Annual Report 2003 - 2004 58 Figure 20: Reported Cases of Cholera 1979 - 2004

18000

16000 15364

14000

12000 10964

10000 9403 Cases Deaths CFR % 8000 Number ofNumber Cases

6000 5327

3863 4000

2172 2000 1509 1082 923 1001 368 319 392 20.261 1.6 0 0 0 0 753.5 6 3.4 936.2 555.510 3.9 0 0 0 71.8 0 1979 1980 1981 1982 1983 1998 1999 2000 2001 2002 2003 2004 Years

4.4.2 Reported outbreks and responses given.

In 2002 there was cholera outbreak in Kwale and Mombasa districts. A total of 319 cases and 10 deaths were reported with a CFR of 3.9%. The year 2003 had no cholera outbreak, but cases of measles in Tana River and Taita Taveta, Dysentery in Tana River and Malindi and Typhoid cases reported in Tana River Malindi districts. While in 2004, various outbreaks were reported; cholera cases in Kwale, Makueni and Taita Taveta districts, Leptospirosis in Bungoma and Mt Elgon districts, and Aflatoxicosis in Makueni, Machakos, Kitui, Thika, Mbeere and Embu districts. Response to the epidemics The districts were given Technical, Financial, drugs and other non pharmaceutical supplies from the Central (national) level.

The response to disease outbreaks has been slow and hence taking time for the outbreak to be contained in the shortest time possible. There is greater need for the division of Disease Outbreak Monitoring Unit to come up with various interventions and empower districts so that they may respond to outbreaks immediately they detect a case rather than DOMU responding to a case of outbreak from the central level.

Annual Report 2003 - 2004 59 4.5 HIV/AIDS – NASCOP Services

4.5.1 Sentinel surveillance

National AIDS/STD Control Programme (NASCOP) has been carrying out Sentinel Surveillance for HIV/AIDS since 1990. HIV/AIDS surveillance is a continuous watchfulness over the distribution and trends through the systematic collection, consolidation, and processing of data in KENYA. Data collected is processed, interpreted and disseminated to development partners and other data users

National AIDS/STD Control Programme (NASCOP) selected specific sites (FACILITIES) at which pre-determined number of pregnant women attending antennal clinics from around the republic are routinely tested for HIV in a regular and consistent way according to a pre-determined WHO/ UNAIDS protocol. People visiting hospitals with Sexual Transmitted infections are also tested for HIV. The recruitment and Testing is anonymous unlinked so that no Results can be linked to any individual at any time.

The main objectives of this HIV surveillance is to:- · Obtain information on the prevalence of HIV infection in selected facilities. · Monitor trends of HIV infection in the over time, and across this sites. · Provide information for making projections of future AIDS cases. · Provide information for programme planning and justification of requested resources, including advocacy for political commitment. · Assessing the impact of intervention programmes. · Estimating the HIV prevalence among the adult population

SURVEILLANCE ACTIVITIES 1990-2003 Surveillance started in 1990 with 23 surveillance sites but dropped to 13 in 1992 due to lack of resources, shortage of supplies for testing and staff. In 1996 these sites were increased again to 16 with additional peri-urban sites. In 2002 with assistance of CDC sites were increased to 38.

CRITERIA FOR SITE SELECTION The sites are a representative of the nation by population characteristics (rural urban), high and low seroprevalence, cultural/behavioural characteristics, historical sites for monitoring trends, adequate number of clients, accessibility for supervision and staff motivation coupled with the presence of a Laboratory and a laboratory technologist to do the HIV testing.

SAMPLE SIZES IN 2003

Table 45: Sample size sentinel sites

Expected M inimum Number sites Number of % that m eet the seroprevalence sample size For this sites that meet sample size sample minimum sample size < 5% 300 11 9 81% 5-10% 200 14 12 85% > 10% 150 11 9 82% OVERALL 83%

REASONS FOR USING PREGNANT WOMEN AND STD PATIENTS.

Pregnant women provide information about sexually active groups of the population and are coming for other services, making it possible to apply anonymous unlinked screening. Many reports indicate that the rates from women measure favorably to a similar sexually active general population. STD patients represent a high-risk population with high potential

Annual Report 2003 - 2004 60 for HIV transmission, are accessible since they come for treatment and therefore no consent is required since Syphilis testing is done as part of routine check up. For both groups, it is the blood that remains after syphilis testing has been done and all identifications stripped that HIV testing is done. Training of Surveillance officers is done annually to ensure confidentiality and good quality testing for quality data. Quality control is done NASCOP central office through retesting of some samples and constant supervision during the data collection period.

Results for 2003 Background characteristics of the ANC clients.

Over 10,000 women were recruited into the exercise. 62 % were from the rural areas and 38% were from the urban areas. The definitions of the residence are as per the Central Bureau of Statistics Census definition.

Table 46: Number of women recruited into the exercise. Characteristics Number Percentage

Sample Size 10616 100%

Residence Rural 6507 62%

Urban 3993 38%

Figure 21: Distribution of Women by age group.

35-39 yrs 40-49 yrs 6% 2% Over 75% of the women were between the 30-34 yrs 15-19 yrs ages of 15 and 29 years. This age group is 14% 17% usually the age that is used to measure the relatively new HIV infections in the most sexually active population. 25-29 yrs 24% 20-24 yrs 37%

Annual Report 2003 - 2004 61 Table 47: HIV Prevalence (%) Rates Of Women In The Sentinel Sites 1990 - 2003. Clients 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Bamba Rural 1 9 5 1 Baringo Mixed 10 6 4 Busia Urban 16 9 29 21 22 21 27 28 28 32 20 15 16 16 Chulaimbo Rural 20 26 35 24 29 25 22 22 Fatima Rural 22 810 Garissa Mixed 4 4 3 14 5 4 7 4 4 9 4 2 Kajiado Mixed 5 6 9 6 8 5 4 Kakamega Mixed 4 12 14 8 13 11 9 9 14 10 10 11 14 13 Kangudo Mixed 14 7 4 Kaplong Rural 3 5 4 4 2 9 6 3 Karurumo Rural 1 9 26 10 6 4 7 Kilifi Mixed 10 5 8 Kisii Urban 1 3 0 2 8 3 15 15 13 11 14 17 14 9 Kisumu Urban 18 18 19 19 29 24 26 32 27 25 33 29 26 26 Kitale Mixed 2 5 20 7 10 9 11 12 8 16 15 13 16 11 Kitui Mixed 0 4 1 7 19 3 3 5 8 7 12 17 6 6 Lodwar Urban 16 18 13 Maragua Rural 10 5 8 8 8 5 Maralal Mixed 15 13 18 Mbale Rural 11 10 15 10 11 23 11 11 8 Meru Mixed 2 1 10 8 15 13 21 28 23 10 5 8 Mombasa Urban 9 16 10 16 10 15 11 16 14 10 14 15 16 Mosoriot Rural 1 12 8 1 1 5 4 3 3 Mt. Elgon Mixed 21 6 5 Mutomo Rural 2 5 4 Nairobi Urban 5 12 13 17 15 16 16 17 17 14 13 11 Nakuru Urban 9 12 12 22 26 10 24 23 25 9 12 12 10 Njambini Rural 4 2 7 6 610 Nyeri Mixed 2 3 8 2 5 20 8 6 15 12 11 8 8 Sirikwa- Rural 5 5 4 Turbo Suba Rural 31 34 41 Tabaka 11 4 9 Teso Rural 6 Thika Mixed 2 9 2 27 39 12 18 31 16 19 11 7 8 Tiwi Rural 16 23 31 21 12 10 710 Wesu- Rural 7 5 3 Wundanyi

Annual Report 2003 - 2004 62 Clients 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Bamba Rural 1 9 5 1 Baringo Mixed 10 6 4 Busia Urban 16 9 29 21 22 21 27 28 28 32 20 15 16 16 Chulaimbo Rural 20 26 35 24 29 25 22 22 Fatima Rural 22 810 Garissa Mixed 4 4 3 14 5 4 7 4 4 9 4 2 Kajiado Mixed 5 6 9 6 8 5 4 Kakamega Mixed 4 12 14 8 13 11 9 9 14 10 10 11 14 13 Kangudo Mixed 14 7 4 Kaplong Rural 3 5 4 4 2 9 6 3 Karurumo Rural 1 9 26 10 6 4 7 Kilifi Mixed 10 5 8 Kisii Urban 1 3 0 2 8 3 15 15 13 11 14 17 14 9 Kisumu Urban 18 18 19 19 29 24 26 32 27 25 33 29 26 26 Kitale Mixed 2 5 20 7 10 9 11 12 8 16 15 13 16 11 Kitui Mixed 0 4 1 7 19 3 3 5 8 7 12 17 6 6 Lodwar Urban 16 18 13 Maragua Rural 10 5 8 8 8 5 Maralal Mixed 15 13 18 Mbale Rural 11 10 15 10 11 23 11 11 8 Meru Mixed 2 1 10 8 15 13 21 28 23 10 5 8 Mombasa Urban 9 16 10 16 10 15 11 16 14 10 14 15 16 Mosoriot Rural 1 12 8 1 1 5 4 3 3 Mt. Elgon Mixed 21 6 5 Mutomo Rural 2 5 4 Nairobi Urban 5 12 13 17 15 16 16 17 17 14 13 11 Nakuru Urban 9 12 12 22 26 10 24 23 25 9 12 12 10 Njambini Rural 4 2 7 6 610 Nyeri Mixed 2 3 8 2 5 20 8 6 15 12 11 8 8 Sirikwa- Rural 5 5 4 Turbo Suba Rural 31 34 41 Tabaka 11 4 9 Teso Rural 6 Thika Mixed 2 9 2 27 39 12 18 31 16 19 11 7 8 Tiwi Rural 16 23 31 21 12 10 710 Wesu- Rural 7 5 3 Wundanyi

Annual Report 2003 - 2004 63 Figure 22: Sites that declined in the last 2 years.

20 14 18 12 16 10 14 12 2002 8 2002 10 6 2003 8 2003 4 6 2

4 % prevalence HIV

HIV prevalence% HIV 2 0 Figure0 23: Sites with Constant HIV prevalence in 2002 and 2003 Mbale Nairobi Nakuru Kisii Figure 24:Sites with increasing prevalenceMutomo in 2002 and 2003. Kitale Mt. Mt. Elgon Wesu/ wun Lodwar Kaplong Maragua Sentinel Sites Kangundo Sentinel Sites

30 45 25 40 20 35 30 15 2002 2003 25 2002 10 20 2003 5 15 HIV prevalence% HIV 0 10

HIV prevalence HIV % 5 0 Kitui Busia Nyeri kisumu Tiwi Mosoriot Suba meru Kilifi Thika Chulaimbo Fatima Tabaka Njabini Maralal

Sentinel Sites Mombasa Karurumo Sentinel sites

Figure 25: Sites with Over 20% Prevalence

The sites in this category are mainly sites in Nyanza province. Suba (41%) is a site that has shown a sharp rise in HIV 45 41 prevalence in the last three year Surveillance has been done in 40 this area. The area is mainly island with fishing as the main 35 economic activity. This is an area where definitely there will be a

30 26 big burden of orphan hood in the next few years. 25 22 20 This is an area where long term plans need to be in place to 15 ensure that the impact of HIV/AIDS will be reduced. 10 Programmes are also needed to ensure that the spread of 5 HIV/AIDS is reduced. 0 Chulaimbo Kisumu Suba Sites

Figure 26: sites with prevalence between 10 and 20 percent in 2003

20 18 18 16 16 16 14 13 13 11 11 12 10 10 10 10 10 8 Prevalence 6 4 2 0

Tiwi Kitale Busia Njabini Nakuru Fatima Nairobi Lodwar Maralal Kakamega Mombasa Sites

Annual Report 2003 - 2004 64 Maralal and Mombasa have had high HIV prevalence among this group. It is surprising that HIV prevalence is high in Lodwar and Maralal considering the life styles in these areas. The life style among this people is Nomadic with a high prevalence of communal women sharing. The other areas are major urban areas with highway influence in HIV as major contributing factor in transmission.

Figure 27: Sites with <10% Prevalence

Sites with Prevalence less than 10% in 2003

10 8888 7 8 6 55 6 44444 333 4 2 1

prevalence 2 0 Kitui Meru Nyeri Thika Mbale Bamba Garissa Kajiado Baringo Kaplong Maragua Mutomo Mosoriot Kangundo Karurumo Mt. Elgon Mt. Wesu/Wund Sirikwa/Turbo site

Many of the sites in this category are rural sites. The urban sites that fell into this category are Nyeri, Meru and Thika. Mbale is a rural site with a notably high prevalence of HIV among the pregnant women.

Figure 28: Trend of HIV among pregnant women in selected Sentinel sites. NAKURU

SIRIKWA 5 18 4.5 16 4 14 3.5 12 3 2.5 10 East 2 8 East 1.5 6 1 4 0.5 2 0 0 2001 2002 2003 1990 1992 1994 1996 2000 2002 NAIROB I 30 25

20

15

10

5

Annual Report 2003 - 2004 65 Figure 30: Trend of the national estimate of the HIV prevalence in Kenya since 1990

The graph shows that Kenya reached the peak of the epidemic in late 1990s. The data also reveals that there has been a decline in prevalence in this decade. The decline in prevalence does not necessarily mean 16 a decline in the rates of new infections. The current prevalence is 9.4% for the republic. The decline 13.4 14 13 13 could mean increased deaths (more deaths than new 12.5 infection) or it may mean actually new infections 11.9 12 11.2 have actually reduced. This system cannot provide information on these factors. 10.4 10.2 10 9.5 9.4 8.5 There is need therefore for a cohort study to monitor HIV incidence. The HIV prevalence could declining 8 7.4 because of a combination of reasons but the 6.3 prevalence is still very high and there is need for a lot 6 5.1 of effort to reduce the prevalence and mitigate on the impact of the scourge. 4 The prevalence from data obtained from pregnant 2 women compares well with that of a sexually active population. The data from a population based survey 0 like the Kenya Health and Demographic Survey may have a lower prevalence than the pregnant women

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 because there are people in the sample who have not had sex as opposed to the pregnant women. The pregnant women data shows prevalence among the sexually active group of the population.

Table 48: Information For Std Patients That Attended Sentinel Clincs In 2003.

Characteristics Number Percentage(%) STD sample size 2719 N/A Gender Male 1041 38.7 Female 1648 61.3 Residence Rural 1602 59.3 Majority of the STD patients were Urban 1100 40.7 women (61 %) from the rural areas. Most of the STD patients were Age group individuals having ages between 15 to <15 10 0.4 34 years of age (75 %). 15-24 931 34.6 25-34 1124 41.8 508 18.9 35-44 116 4.3 >44

Annual Report 2003 - 2004 66 Table 49: shows the most common indicators.

Indicator 2003

National adult prevalence. 15-49 9.4%

Number adults infected 1,750,000 Urban adult prevalence 13.8 No. urban adults infected 525,000

Rural adult prevalence 7.4% No. rural adults infected 1,125,000

Figure 31: Prevalence Of Hiv Among Std Patients Since 1997 nSince year 2000, there is a declining 45 41.8 trend of HIV infection among STD clients. 40 nHIV prevalence is high among all women 33.9 35 32.3 31.2 in all categories of marital status as 30 26.7 compared to men. There is need to 23.4 strengthen HIV prevention interventions 25 22.7 among women. 20 nSTD clients are more infected with HIV % prevalence 15 as compared to the women who don¶t have 10 STDs. People with STDs are people who 5 have had unprotected sex with infected 0 individuals. This group of people can easily 1997 1998 1999 2000 2001 2002 2003 be infected with HIV. Years

Annual Report 2003 - 2004 67 HIV PREVALENCE BY AGE GROUP AND GENDER (2003)

Status Female Male Women with monogamous marital status and Single 81(21.4) 49(23.9) the single status have a higher prevalence than their male counterparts for people with Monogamous 191(50.4) 117(57.1) STIs. Polygamous 54(14.2) 28(13.7) Divorced/Sepa 30(7.9) 4(2.0) rated Widowed 23(6.1) 7(3.4) Figure 32: HIV prevalence among STD patients by age group

Data from the two years 35 indicates that all age groups 30.4 have a higher HIV 30 27.9 26.1 25.6 25.5 25 prevalence but the most 25

21.2 2002 affected are the economically 20 20 active groups aged between 16.4 15.8 15 2003 25 years to 44 years of age. 10 There is no significant % prevalence 5 difference in the HIV prevalence for these 0 syndromes in two years; <15 15-25 25-34 35-44 >45 Genital Ulcers has a chance of HIV infection Age groups for the years. Hence Genital Ulcer disease increases the likelihood of HIV infection. In general therefore, presence of STDs shows that there is higher likelihood of infection. This is because people in this category obviously did not use condoms during sex.

Annual Report 2003 - 2004 68 Figure 33: HIV rates by std syndromes (2002/2003)

30

25 23 22 20.3 21.4 20 15 10 % prevalence 5 0 PID Vaginal discharge

Figure 34: HIV prevalence between std and antenatal patients (1999-2003)

40 HIV prevalence in both 33.9 STD and ANC patients 35 31.2 have significantly declined 30 26.7 over the years indicated. 23.4 25 22.7 The data also reveals that 20 17.1 17.7 STD people with STDs have 2 times likelihood of 15 13 ANC 10.2 9.4 infection to other sexually

% prevalence 10 active group of the 5 population. 0 1999 2000 2001 2002 2003 Years

4.5.2 Trained ARV officers

The total number of officers trained in Antiretroviral Therapy is 1740 in 2003/2004. This data does not contain the number of officers trained per province.

Table 50: National Vct Uptake by gender

Number Tested Number Positive % Positive Year Male Female Total Male Female Total Male Female Total 2001 9694 8457 18151 1475 1922 3397 15.22 22.73 18.72 2002 38638 33963 72601 4719 7192 11911 12.21 21.18 16.41 2003 99281 79253 178534 9840 17095 26935 9.91 21.57 15.09 2004 172647 162148 334795 17117 32671 49788 9.91 20.15 14.87

Total 320,260 283,821 604,081 33,151 58,880 92,031 10.35 20.75 15.23

Annual Report 2003 - 2004 69 Figure 35: National vct uptake 2001 – 2004

200000

180000 172647 162148 160000

140000

120000 NUMBER 2001 99281 2002 100000 2003 79253 2004 80000

60000

38638 40000 33963 32671

20000 17117 17095 9694 9840 8457 4719 7192 1475 1922 0 Male Male +ve Female Female +ve GENDER

Annual Report 2003 - 2004 70 Figure 36:National vct sero-prevalence 2001 - 2004

25

22.73 21.57 21.18 20.15 20

15.22 15 PREVALENCE 12.21 Male Female 9.91 9.91 10

5

0 2001 2002 2003 2004 YEAR

Annual Report 2003 - 2004 71 Table 51: National estimates 2003 hiv/aids

Rural Urban Province District Site Site Rural Prevalence Urban Prevalence InfectedTotal Rural InfectedTotal Urban InfectedTotal District Prevalence InfectedTotal Provincial Provincial Prevalence 158,59 14.2 158,5 14.20 Nairobi Nairobi None Nairobi 0.00 14.20 0 158,592 2 0 92 % Central Kiambu Njambini Thika 6.30 7 14,809 12,710 27,519 6.60 Kirinyaga Maragua Nyeri 7.90 7.90 17,973 2,266 20,239 7.90 Muranga Maragua Thika 7.90 7.00 10,402 2,435 12,837 7.70 Nyandaru a Njambini Nyeri 6.30 7.90 11,973 2,862 14,835 6.60 Nyeri Maragua Nyeri 6.30 7.90 13,753 10,108 23,861 6.90 Thika Maragua Thika 6.30 7.00 15,590 7,807 23,397 6.50 135,0 6.90 Maragua Maragua Nyeri 6.30 7.90 8,621 3,767 12,388 6.70 76 % Coast Kilifi Bamba Kilifi 4.00 5.50 6,564 4,764 11,328 4.50 Kwale Tiwi Kilifi 6.50 5.50 12,814 2,153 14,967 6.30 Mombas Lamu Bamba a 4.00 14.50 1,145 1,246 2,391 6.40 Wesu/ Mombas 12.5 Mombasa Wundanyi a 5.80 14.50 5,696 48,378 54,074 0 Taita Wesu/ Mombas 9.30 Taveta Wundanyi a 5.80% 15% 4,316 7,362 11,678 % Tana 4.00 River Tiwi Garissa 4.00% 4.30% 3,082 333 3,415 % 4.70 104,2 8.00 Malindi Bamba Kilifi 4.00% 5.50% 2,975 3,374 6,349 % 02 % Eastern Embu Karurumo Meru 4.00% 5.10% 3,881 2,832 6,713 4.40% 5.20 Isiolo Mutomo Meru 5.30% 5.10% 1,396 1,136 2,532 % 5.50 Kitui Mutomo Kitui 5.30% 6.10% 8,890 3,372 12,262 % 5.50 Makueni Mutomo Kitui 5.30% 6.10% 14,749 4,147 18,896 % 6.40 Machakos Kangundo Kitui 6.70% 6.10% 16,044 12,176 28,220 % 4.00 Marsabit Karurumo Garissa 4.00% 4.30% 1,864 388 2,252 % 4.00 Mbeere Karurumo Meru 4.00% 5.10% 3,167 83 3,250 % Meru 4.30 Central Karurumo Meru 4.00% 5.10% 8,471 3,433 11,904 % 4.20 Moyale Tiwi Garissa 4.00% 4.30% 426 537 963 % 6.50 Mwingi Kangundo Kitui 6.70% 6.10% 6,333 2,041 8,374 % Meru 4.00 North Karurumo Meru 4.00% 5.10% 11,116 396 11,512 % 4.00 Tharaka Karurumo Meru 4.00% 5.10% 1,974 0 1,974 % Meru 4.00 113,1 5.10 South Karurumo Meru 4.00% 5.10% 4,092 186 4,278 % 30 % N/Easter Garissa Tiwi Garissa 4.00% 4.30% 6,384 1,590 7,974 4.10

Annual Report 2003 - 2004 72 Rural Urban Province District Site Site Rural Prevalence Urban Prevalence Infected Total Rural Infected Total Urban Infected Total District Prevalence Infected Total Provincial Provincial Prevalence North % Eastern 4.10 Mandera Tiwi Garissa 4.00% 4.30% 3,591 1,033 4,624 % 4.10 18,69 4.10 Wajir Tiwi Garissa 4.00% 4.30% 4,520 1,577 6,097 % 5 % Kisii 7.40 Nyanza Central Tabaka Kisii 4.30% 13.70% 7,010 10,896 17,906 % Homa- 34.00 34.0 Bay Suba Suba % 34.00% 35,625 9,859 45,484 0% 21.80 24.4 Kisumu Chulaimbo Kisumu % 26.00% 21,651 42,449 64,100 0% 7.80 Kuria Tabaka Kisii 4.30% 13.70% 1,870 3,537 5,407 % 34.00 34.0 Migori Suba Suba % 34.00% 38,087 46,015 84,102 0% 6.90 Nyamira Tabaka Kisii 4.30% 13.70% 7,660 9,099 16,759 % Rachuony 34.00 34.0 o Suba Suba % 34.00% 31,869 15,001 46,870 0% 21.80 22.9 Siaya Chulaimbo Kisumu % 26.00% 32,717 14,682 47,399 0% 34.00 34.0 Suba Suba Suba % 34.00% 17,213 8,191 25,404 0% 21.80 22.8 Nyando Chulaimbo Kisumu % 26.00% 22,992 9,083 32,075 0% 21.80 22.5 409,6 21.90 Bondo Chulaimbo Kisumu % 26.00% 19,543 4,562 24,105 0% 11 % Rift Sirikwa/ 4.60 Valley Baringo Turbo Baringo 4.50% 5.50% 4,868 645 5,513 % 5.90 Bomet Kaplong Baringo 6.00% 5.50% 7,300 2,621 9,921 % Sirikwa/ 4.70 Keiyo Turbo Baringo 4.50% 5.50% 2,569 661 3,230 % 7.00 Kajiado Fatima Kajiado 7.50% 5.20% 12,339 2,330 14,669 % 5.80 Kericho Kaplong Baringo 6.00% 5.50% 9,535 4,274 13,809 % Sirikwa/ 4.80 Koibatek Turbo Baringo 4.50% 5.50% 2,059 1,134 3,193 % 7.60 Laikipia Njabini Nakuru 6.30% 11.80% 7,666 4,457 12,123 % 2.90 Marakwet Mosoriot Baringo 2.90% 5.50% 1,831 0 1,831 % 8.00 Nakuru Njabini Nakuru 6.30% 11.80% 26,945 22,457 49,402 % 3.50 Nandi Mosoriot Baringo 2.90% 5.50% 6,125 3,512 9,637 % 7.20 Narok Fatima Kajiado 7.50% 5.20% 10,569 1,097 11,666 % 9.00 Samburu Fatima Samburu 7.50% 12.50% 3,339 2,391 5,730 %

Annual Report 2003 - 2004 73 Rural Urban Province District Site Site Rural Prevalence Urban Prevalence Infected Total Rural Infected Total Urban Infected Total District Prevalence Infected Total Provincial Provincial Prevalence Trans- 7.40 Mara Fatima Kajiado 7.50% 5.20% 5,461 132 5,593 % Trans- 4.70 Nzoia Mosoriot Kitale 4.50% 16.50% 12,072 618 12,690 % 8.40 Turkana Fatima Lodwar 4.50% 18.00% 14,293 3,374 17,667 % Uasin Sirikwa/ 5.80 Gishu Turbo Kitale 4.50% 16.50% 12,922 5,787 18,709 % West Sirikwa/ 5.20 Pokot Turbo Lodwar 4.50% 18.00% 19,694 4,401 24,095 % 6.00 256,6 6.20 Bureti Kaplong Baringo 6.00% 5.50% 37,180 32 37,212 % 90 % Mt. 6.10 Western Bungoma Teso Elgon 6.30% 5.50% 17,851 6,530 24,381 % 10.3 Busia Teso Busia 6.30% 15.50% 5,762 10,973 16,735 0% Mt. 6.20 Mt. Elgon Teso Elgon 6.30% 5.50% 3,551 258 3,809 % Kakameg Kakame 10.80 11.1 a Mbale ga % 14.30% 57,870 7,188 65,058 0% Kakame 10.80 12.1 Lugari Mbale ga % 14.30% 6,713 5,320 12,033 0% 8.70 Teso Teso Busia 6.10% 15.50% 3,664 3,549 7,213 % Kakame 10.80 11.7 Vihiga Mbale ga % 14.30% 17,669 7,857 25,526 0% Butere/ Kakame 10.80 11.7 179,9 9.90 Mumias Mbale ga % 14.30% 16,976 8,268 25,244 0% 99 %

Total 1,375,9 9.20 1,375, 9.20 Kenya Kenya 789671 586,324 95 % 995 %

4.5.3 Blood safety

Blood safety program was started in NASCOP in 1989. The broad objective of blood safety program is to minimize/eradicate the transmission of HIV/AIDS and other TTIs through safe blood products and blood transfusion. Other specific objectives fall within various programmes such as:- · Sentinel Surveillance · Voluntary counseling and Testing · Prevention of Mother to child Transmission · Antiretroviral · Tuberculosis Other activities include guiding the program Director on laboratory/Blood safety issues, facilitation of blood safety meetings, evaluation of new testing kits, distribution of HIV test kits, Supply of surveillance materials and validation of Sentinel surveillance samples. Other tasks carried by the Blood safety unit includes:-

· Monitoring of HIV machines. · Monitoring kits performance in the field and especially the approved kits. Coordination of Quality assurance program is also done targeting - Diagnostics, Voluntary counseling and Testing - PMTCT, Antiretroviral and Surveillance

Annual Report 2003 - 2004 74 Coordination of trainings such as:- - Blood donor recruiters, HIV testing technologists, HIV test kits evaluation technologists - Blood transfusion transcribers, and National sentinel surveillance trainings All the above mentioned activities cannot be a success without mentioning the input of various stakeholders such as CDC, FHI, JSI, WHO, Futures Group and other who have really assisted not only Blood safety unit but NASCOP as Whole.

Table 52: Prevention Mother To Child Transmission Of Hiv/Aids (Pmtct) 2004

Province 1st ANC ANC HIV ANC HIV ANC HIV Mothers Infants ANC revisits status Tested +ve receiving receiving visits NVP NVP Central 15,333 51,675 7,867 6,905 448 236 47 Coast 3,246 521 1,627 2,209 149 41 16 Eastern 16,055 37,771 6,207 7,816 326 84 3 Nairobi 11,351 26,304 10,870 9,845 998 238 44 North Eastern 0 0 0 0 0 0 0 Nyanza 28,050 44,636 12,501 14,573 3,406 967 659 Rift Valley 50,907 102,608 26,212 26,091 2,828 966 434 Western 1,312 1,124 605 559 69 41 11 Total 126,254 264,639 65,889 67,998 8,224 2573 1214

PMTCT has not yet taken route in North Eastern province. Almost 30% of mothers tested HIV positive have accepted to be put on Nevirapine treatment while the number of children receiving Nevirapine are half (50%) of mothers receiving the treatment. The acceptance is generally low.

Figure 37: PMTCT uptake by province 2004

120,000

100,000

80,000

1st ANC visits ANC revisits 60,000 ANC HIV status

NUMBER ANC HIV Tested ANC HIV +ve

40,000

20,000

0 Central Coast Eastern Nairobi North Nyanza Rift Valley Western Eastern PROVINCE

Annual Report 2003 - 2004 75 Table 53: PMTCT uptake maternity unit 2004

Province Number Mothers Maternity Maternity Maternity Maternity Infants of screened HIV HIV HIV +ve NVP NVP in deliveries counseled Tested dispensed Maternity Central 20,280 6,975 152 70 29 78 222 Coast 0 2,216 0 7 0 0 0 Eastern 15,945 8,238 3,236 422 38 48 59 Nairobi 763 9,904 42 59 10 16 7 North Eastern 0 0 0 0 0 0 0 Nyanza 13,091 14,921 660 348 202 223 979 Rift Valley 21,539 27,155 1,137 1,064 181 222 357 Western 276 563 22 4 1 2 3 Total 71,894 69,972 5,249 1,974 461 589 1627

4.5.4 Home based care Home Based Care (HBC) in Kenya is practiced through the Primary Health Care/, Community Based Health Care since the Al- Manta declaration of 1978. HBC for HIV/AIDS have been complicated by stigma and discrimination attached to the disease and the fact that HIV mode of transmission is surrounded with a lot of myths. Prolonged hospital care for patients with HIV/AIDS puts too much constraints in the hospital budgets and compromises the resources that should be utilized on emergency cases.

Effective HBC will help decongest hospitals. Currently about 65% of hospital bed occupancy suffer from AIDS related illnesses. HBC puts the DHMTs at the best position to play major coordinating role while community, members and the family participate together with health facility staff as advocates to reduce stigma, discrimination and demystify the myths surrounding the disease.

Patients put on ARVs are not mostly admitted to hospitals but take drugs home and therefore require adherence follow- ups, nutritional support, spiritual support, social support among other things. This can be done in a cost effective way through provision of comprehensive HBC programme.

Achievements · Produced several educational materials i.e. o National policy on HBC o Hand book for health workers o Curriculum for training health workers and community volunteers/ care givers. o Flip chart o User manuals among others · Ministry of Health through NASCOP with development partners has produced a National strategic plan 2005- 2010 for her activities. · Created a unit specifically handling HBC in NASCOP and headed by a senior Doctor. · Establishing a national directory to identify all groups providing HBC and where they are based. · Trained 120 TOTs to orientate health workers on HBC. · Mild May international training TOFs and meters to support implementation of the HBC in Nyanza province and rollout the programme country wide.

Development Partners: · CDC · Futures group · Mild May international · MSF – Medicine Sans Frontieres ( France and Belgium)

Annual Report 2003 - 2004 76 Constraints: 1. Inadequate funding. 2. Stigma. 3. Lack of co-ordination and effective supervision. HBC is not mainstreamed into the general health systems. 4. Inadequate assessment of the type of needs for care and support for the HIV/AIDS patients. 5. Lack of reports and reporting tools.

Way forward: · To orientation of PHMTs and DHMTs. · Mainstreaming HBC into general health services. · Procurement and distribution of HBC materials/kits · Training support centre staff on comprehensive care and equipping them with HBC kits. · Training community – based volunteers and family members as care givers. · Provide effective supervision · Provide reporting tools and give regular feedback.

4.6 Expanded programme on immunizations (EPI) services

Expanded Programme on Immunization (EPI) services in Kenya started in early 1980s. Several interventions have been carried out to boost these services and a lot have been achieved in terms of; Ø Reducing the morbidity and mortality of the immunizable diseases. Ø Reducing the childhood and infant mortality. Ø Making the services accessible and affordable to the community. Ø Case based disease surveillance for Acute Flaccid Paralysis (AFP), Measles and Maternal Neonatal Tetanus. Ø Equipping facilities and districts with cold chain equipment and support in maintenance. Ø Procurement and distribution of potent vaccines and Vitamin “A”. Ø Training of facility staff and managers at all levels Ø Monitoring and Evaluation.

DATA QUALITY AUDIT (DQA)

The Data Quality Audit (DQA) is designed to calculate the measure of accuracy of reporting of a country’s “verification factor” in this case pentavalent 1 and pentavalent 3 vaccinations which are given to children less than one year of age. The DQA is conducted annually by the Global Alliance of Vaccines and Immunizations (GAVI) as part of its programme to assist countries receive her support and improve the quality of information systems. To improve the country’s immunization reporting systems GAVI, UNICEF, WHO and other development partners with dedication of health facility staff stepped in to provide technical, financial and motivated in addressing the shortfalls of the 2001 and 2002 DQAs. The MOH through Kenya Expanded Programme on Immunization (KEPI) in 2004 achieved a high data verification factor of 86% up from 49% in 2002. 86% verification factor indicated that Kenya’s data on immunization is reliable and can be used internationally to influence policy and make evidence based decision making. The factor reflects the accuracy in reporting values for pentavalent 3 < 1 to reflect the exact number of clients tallied at the health facility and reports submitted at the district and national levels.

At least one facility staff was trained with the main expected outcomes; I mproved cold chain maintenance. Use of new EPI reporting tools (monthly immunization tally and summary sheets, vaccine ledgers, permanent registers) Target setting for health facilities (< 1 year and Child Bearing Age women). Use of new monitoring tool for coverage and dropout rates (see example in figure ----- Busia district) Facility based micro-plans. Vaccine forecasting Capturing of vaccine wastages (vaccine monitoring)

EPI INFO SOFTWARE

In 2003 MoH- KEPI embarked on collaboration with WHO and CDC Atlanta to develop and supported a system that could monitor and evaluate the immunization programme and provide regular feedback. EPI INFO was identified as a suitable software package and in January 2004 the module was introduce at the National level and June 2004

Annual Report 2003 - 2004 77 decentralized to the provinces and further piloting in three poor performing districts of Migori, Pumwani and Busia in Nyanza, Nairobi and western province respectively with the technical support of CDC.

Figure 38 :National Epi Timeliness And Completeness Of Reports 2003 And 2004 By Province

140%

118% 120%

100%100% 99% 98% 100%100% 99% 99% 100% 100%100% 100%100% 100%100% 99%100% 100% 96% 93% 95%

86% 85% 83% 80% 80% 80% 75% 75% Time 2003. RATE 73% Comp 2003. 67% 66% 62% Time 2004. 58% 58% 60% Comp 2004.

44%

40% 36%

20%

0% N/Eastern Coast Nyanza Rift Valley Eastern Naiorbi Central Western Kenya PROVINCE

Annual Report 2003 - 2004 78 Figure 39: EPI Monitoring graph 2004

Annual Report 2003 - 2004 79 Table 54: Epi Specific Coverages, Accessibility And Utilization By Province 2004 DPT3 MSLS - - Province Surviving Infants DPT1 DPT3 Measles FIC % DPT1 % DPT3 % MSLS % FIC Dropout DPT1 Dropout DPT1 Access Utilization Category Nairobi 95615 90898 83177 73630 68616 95 87 77 72 8% 19% Good Good 1 Rift Valley 328232 267317 232311 192729 160199 81 71 59 49 13% 28% Good Poor 2 Western 177320 147629 127029 111463 96636 83 72 63 54 14% 24% Good Poor 2 Nyanza 200718 163450 136991 113028 96249 81 68 56 48 16% 31% Good Poor 2 Coast 111949 86402 76104 66916 63327 77 68 60 57 12% 23% Poor Poor 4 Central 120295 116499 110961 103772 100181 97 92 86 83 5% 11% Good Good 1 Eastern 187342 159639 151703 130962 121537 85 81 70 65 5% 18% Good Good 1 N.Eastern 33137 26147 20023 21346 18051 79 60 64 54 23% 18% Poor Poor 4 National 1254608 1057981 938299 813846 724796 84 75 65 58 11% 23% Good Poor 2

Table 55: Epi Specific Coverages, Accessibility And Utilization By Province 2003 - - C Province Surviving Infants DPT1 DPT3 Measles FIC % DPT1 % DPT3 % MSLS % FI Dropout DPT1 DPT3 Dropout DPT1 MSLS Access Utilization Category

Nairobi 86527 97109 84109 78283 77859 112 97 90 90 13% 19% Good Poor 2 Rift Valley 315276 254902 210937 198202 156041 81 67 63 49 17% 22% Good Poor 2 Western 167511 149953 112312 108807 95377 90 67 65 57 25% 27% Good Poor 2 Nyanza 200670 162826 127455 114270 94808 81 64 57 47 22% 30% Good Poor 2 Coast 108692 97548 85049 78620 72937 90 78 72 67 13% 19% Good Poor 2 Central 127682 113200 105992 103384 99933 89 83 81 78 6% 9% Good Good 1 Eastern 186136 158723 145408 131202 115416 85 78 70 62 8% 17% Good Good 1 N.Eastern 28725 28756 22243 24337 19115 100 77 85 67 23% 15% Good Poor 2 National 1221219 1063017 893505 837105 731486 87 73 69 60 16% 21% Good Poor 2

Annual Report 2003 - 2004 80 Epi Specific Coverages, Accessibility And Utilization By Province 2002 - - Province Surviving Infants DPT1 DPT3 Measles FIC % DPT1 % DPT3 MSLS % % FIC Dropout DPT1 DPT3 Dropout DPT1 MSLS Access Utilizatio n Category Nairobi 84,241 70098 65648 52421 50833 83 78 62 60 6% 25% Good Poor 1 Rift Valley 307,660 237364 203211 171326 129745 77 66 56 42 14% 28% Poor Poor 4 Western 163,089 136522 98399 83440 73115 84 60 51 45 28% 39% Good Poor 2 Nyanza 195,373 139483 107808 91031 59482 71 55 47 30 23% 35% Poor Poor 4 Coast 105,822 75106 65856 58177 55392 71 62 55 52 12% 23% Poor Poor 4 Central 124,309 101348 93526 85183 74070 82 75 69 60 8% 16% Good Good 1 Eastern 181,223 158791 139104 110770 98690 88 77 61 54 12% 30% Good Poor 2 N.Eastern 27,967 21823 17095 17643 12525 78 61 63 45 22% 19% Poor Poor 4

National 1189684 940535 790647 669991 553852 79 66 56 47 16% 29% Poor Poor 4

Annual Report 2003 - 2004 81 Table 56: Summary coverage for antigens (<1y) by district 1/2004 to 12/2004 cod District e % T2 T3 L1 V1 V2 V3 asles Fully u_L1 Immu %Cov YF_L1 Infants VA_L1 Measles_ %CovDP %CovDP %CovOP %CovOP %CovOP %CovMe %CovYF Surviving DPT1_L1 DPT2_L1 DPT3_L1 %CovVA CovDPT1 OPV1_L1 OPV2_L1 OPV3_L1 FullyImm 101 Central 10485 5743 55 5720 55 5328 51 5602 53 5618 54 5108 49 5605 53 3524 34 0 0 5126 49 102 Kasarani 15304 22719 148 22317 146 21880 143 21873 143 21604 141 20852 136 17554 115 11959 78 0 0 17758 116 103 Westlands 9565 8645 90 8089 85 7952 83 8598 90 8067 84 8010 84 7177 75 4925 51 0 0 6512 68 104 Embakasi 19130 15789 83 14641 77 14295 75 15837 83 15030 79 14192 74 14310 75 7027 37 0 0 13326 70 105 Kibera 12435 9150 74 8050 65 7503 60 9242 74 8009 64 7455 60 5849 47 5071 41 0 0 5429 44 106 Pumwani 8609 8004 93 7258 84 7070 82 7966 93 7255 84 6962 81 6083 71 2057 24 0 0 5007 58 107 Dagoretti 11478 12095 105 11188 97 11485 100 11900 104 11336 99 10983 96 9775 85 6175 54 0 0 8368 73 108 Makadara 8609 8753 102 7937 92 7664 89 8664 101 8113 94 7769 90 7277 85 5215 61 0 0 7090 82 NAIROBI 95615 90898 95 85200 89 83177 87 89682 94 85032 89 81331 85 73630 77 45953 48 2 0 68616 72 201 Kiambu 25651 24970 97 24040 94 23120 90 23839 93 23162 90 22548 88 20168 79 15957 62 0 0 18557 72 202 Kirinyaga 13633 13743 101 13691 100 13519 99 13743 101 13691 100 13519 99 12674 93 10621 78 0 0 12672 93 203 Muranga 9153 8983 98 8887 97 9229 101 8890 97 8919 97 9087 99 8496 93 5644 62 0 0 8457 92 204 Nyandarua 19324 18860 98 18334 95 17719 92 18804 97 18341 95 17782 92 16127 83 8541 44 0 0 15606 81 205 Nyeri 19002 16982 89 16794 88 16285 86 16864 89 16801 88 16327 86 15899 84 12669 67 0 0 15376 81 206 Thika 21210 20693 98 20007 94 19519 92 20604 97 19903 94 19469 92 18387 87 127173 600 0 0 18012 85 207 Maragua 12322 12268 100 11727 95 11570 94 11954 97 11577 94 11448 93 12021 98 8264 67 0 0 11501 93 CENTRAL 120295 116499 97 113480 94 110961 92 114698 95 112394 93 110180 92 103772 86 188869 157 0 0 100181 83 301 Kilifi 25723 19635 76 18130 70 16650 65 18699 73 19768 77 18801 73 16101 63 12084 47 3 0 15667 61 302 Kwale 23438 17771 76 17259 74 16015 68 17852 76 17595 75 16667 71 14344 61 8350 36 0 0 13199 56 303 Lamu 2519 3278 130 3067 122 2949 117 3288 131 3020 120 2931 116 2543 101 1414 56 0 0 2107 84 304 Mombasa 29129 18893 65 18208 63 17958 62 17862 61 17883 61 17908 61 14321 49 6840 23 0 0 15171 52 305 Taita 8470 7546 89 7351 87 7129 84 7465 88 7362 87 6942 82 6308 74 5878 69 0 0 5714 67 Taveta 306 Tana River 8481 5828 69 4853 57 4536 53 5390 64 4926 58 4650 55 3836 45 2368 28 0 0 2968 35 307 Malindi 14189 13451 95 11873 84 10867 77 12521 88 12133 86 11264 79 9463 67 9759 69 0 0 8501 60 COAST 111949 86402 77 80741 72 76104 68 83077 74 82687 74 79163 71 66916 60 46693 42 24 0 63327 57 401 Embu 8693 8251 95 8427 97 8013 92 8088 93 7907 91 8020 92 7645 88 5254 60 0 0 7487 86 402 Isiolo 4374 4090 94 3787 87 3617 83 3928 90 3705 85 3407 78 2997 69 1149 26 0 0 2821 64 403 Kitui 23884 18933 79 18262 76 19127 80 18950 79 18238 76 18168 76 14069 59 4611 19 0 0 12978 54 404 Machakos 36907 30227 82 30093 82 29369 80 30029 81 29679 80 29689 80 27535 75 5450 15 0 0 25760 70 405 Marsabit 4808 3671 76 3356 70 3165 66 3700 77 3306 69 3130 65 2852 59 1268 26 0 0 2463 51 406 Meru 14381 14593 101 14001 97 13859 96 14254 99 13980 97 13826 96 12682 88 6694 47 0 0 12615 88 Central 407 Makueni 33152 23559 71 22805 69 22385 68 23234 70 23535 71 22797 69 19860 60 5490 17 0 0 17902 54 408 Meru 6223 6370 102 5823 94 5520 89 6094 98 5663 91 5648 91 5412 87 2877 46 0 0 5446 88

Annual Report 2003 - 2004 82 cod District e % T2 T3 L1 V1 V2 V3 asles Fully u_L1 Immu %Cov YF_L1 Infants VA_L1 Measles_ %CovDP %CovDP %CovOP %CovOP %CovOP %CovMe %CovYF Surviving DPT1_L1 DPT2_L1 DPT3_L1 %CovVA CovDPT1 OPV1_L1 OPV2_L1 OPV3_L1 FullyImm South 409 Meru 26889 23453 87 21125 79 22372 83 23578 88 21761 81 22201 83 17763 66 4724 18 0 0 15658 58 North 410 Mwingi 14164 13183 93 11477 81 11908 84 11602 82 11713 83 11441 81 9115 64 1749 12 0 0 7766 55 411 Mbeere 7582 6866 91 6790 90 6801 90 6809 90 6760 89 6801 90 6373 84 3288 43 0 0 6348 84 412 Moyale 2135 2946 138 2813 132 2585 121 2920 137 2811 132 2624 123 2057 96 858 40 0 0 1971 92 413 Tharaka 4150 3497 84 3279 79 2982 72 3487 84 3300 80 2985 72 2602 63 918 22 0 0 2322 56 EASTERN 187342 159639 85 152038 81 151703 81 156673 84 152358 81 150737 80 130962 70 44330 24 0 0 121537 65

code District_ 2 3 1 2 3 1 u % sles _L1 Fully Imm %Cov Infants YF_L1 VA_L1 %CovYF Surviving DPT1_L1 DPT2_L1 DPT3_L1 CovDPT1 OPV1_L1 OPV2_L1 OPV3_L1 %Cov VA %CovMea %CovDPT %CovDPT Measles_L %CovOPV %CovOPV %CovOPV FullyImmu 501 Garissa 12207 12391 102 11492 94 9810 80 11289 92 10288 84 8992 74 10494 86 7013 57 0 0 9323 76 502 Mandera 7939 4823 61 4369 55 3743 47 4802 60 3921 49 3604 45 3226 41 1112 14 0 0 2554 32 503 Wajir 10837 7101 66 5286 49 4977 46 6993 65 5216 48 4960 46 5668 52 3491 32 0 0 4538 42 504 Ijara 2154 1832 85 1573 73 1493 69 1914 89 1563 73 1396 65 1958 91 1893 88 0 0 1636 76 NORTH EASTERN 33137 26147 79 22720 69 20023 60 24998 75 20988 63 18952 57 21346 64 13509 41 0 0 18051 54 601 Kisii Central 20420 17415 85 17001 83 16412 80 17395 85 17040 83 16426 80 16494 81 7580 37 0 0 14551 71 602 Kisumu 22044 17042 77 15142 69 13534 61 16867 77 15184 69 13732 62 11432 52 6106 28 0 0 9235 42 603 Siaya 19239 12152 63 11042 57 9347 49 12201 63 10039 52 8895 46 6523 34 1777 9 0 0 4406 23 604 Homa Bay 14367 13708 95 10875 76 11701 81 13119 91 10623 74 10985 76 9373 65 5461 38 0 0 8520 59 605 Nyamira 19658 19237 98 18792 96 18904 96 19211 98 17528 89 16989 86 16868 86 8733 44 0 0 16299 83 606 Migori 27202 21667 80 18772 69 15976 59 20870 77 17578 65 15318 56 12197 45 8386 31 0 0 8339 31 607 Kuria 9002 8013 89 7152 79 6581 73 8028 89 7657 85 7101 79 5634 63 3016 34 0 0 4196 47 608 Suba 8000 5894 74 4829 60 3987 50 5510 69 4819 60 3939 49 3628 45 3194 40 0 0 3499 44 609 Rachuonyo 14478 10834 75 9047 62 8513 59 10088 70 8711 60 8157 56 5883 41 3819 26 0 0 5073 35 610 Gucha 20817 17601 85 17611 85 16353 79 16735 80 16196 78 15318 74 13483 65 10688 51 0 0 12870 62 611 Bondo 11864 8305 70 7018 59 6383 54 8120 68 7189 61 6526 55 4689 40 1010 9 0 0 3675 31 612 Nyando 13627 11582 85 10210 75 9300 68 11388 84 10391 76 9420 69 6824 50 7155 53 0 0 5586 41 NYANZA 200718 163450 81 147491 73 136991 68 159532 79 142955 71 132806 66 113028 56 66925 33 0 0 96249 48

701 Kajiado 20472 14887 73 14361 70 12673 62 15033 73 13307 65 12735 62 11311 55 3688 18 376 2 10200 50 702 Kericho 21388 15893 74 15167 71 13511 63 15034 70 13899 65 13156 62 11159 52 3158 15 191 1 9221 43 703 Laikipia 14641 11301 77 10600 72 10331 71 11099 76 10543 72 10308 70 8542 58 4260 29 81 1 7552 52

Annual Report 2003 - 2004 83 code District_ 2 3 1 2 3 1 u % sles _L1 Fully Imm %Cov Infants YF_L1 VA_L1 %CovYF Surviving DPT1_L1 DPT2_L1 DPT3_L1 CovDPT1 OPV1_L1 OPV2_L1 OPV3_L1 %Cov VA %Cov %CovMea %CovDPT %CovDPT Measles_L %CovOPV %CovOPV %CovOPV FullyImmu 704 Nakuru 54046 47370 88 45329 84 43350 80 46198 85 46088 85 43182 80 36905 68 20235 37 13446 25 30477 56 705 Narok 21332 14269 67 13584 64 13157 62 13648 64 13283 62 12387 58 8874 42 5067 24 0 0 6947 33 706 Bomet 19047 13109 69 13649 72 10342 54 10451 55 10338 54 9067 48 7117 37 2067 11 149 1 5070 27 707 Trans Mara 8643 10136 117 9721 112 8868 103 10172 118 9604 111 9029 104 6524 75 3369 39 0 0 5419 63 708 Buret 15006 14559 97 14709 98 14987 100 14086 94 14253 95 14330 95 11613 77 8387 56 0 0 11955 80 801 Baringo 12585 8953 71 8758 70 8247 66 8822 70 8509 68 8150 65 6808 54 5784 46 6095 48 6139 49 802 Marakwet 6324 6207 98 5904 93 5551 88 5968 94 5693 90 5276 83 4699 74 2029 32 2545 40 3483 55 803 Nandi North 15247 10776 71 9875 65 9635 63 10522 69 10494 69 9773 64 9048 59 4818 32 0 0 8621 57 804 Samburu 6994 5882 84 5542 79 5108 73 5953 85 5517 79 5065 72 3650 52 2784 40 0 0 3397 49 805 Turkana 12059 11165 93 9598 80 8281 69 10813 90 9396 78 7927 66 7178 60 4588 38 333 3 5626 47 806 West Pokot 16359 12878 79 11078 68 9721 59 12285 75 11001 67 9332 57 7509 46 3122 19 0 0 5459 33 807 Trans Nzoia 30203 18641 62 17782 59 16010 53 18921 63 18281 61 16145 53 15004 50 1090 4 949 3 11633 39 808 Uasin Gishu 29075 23728 82 22189 76 21055 72 23455 81 22413 77 20678 71 18792 65 10491 36 77 0 16009 55 809 Keiyo 6058 6242 103 6125 101 5833 96 5973 99 6075 100 5865 97 5390 89 2384 39 2842 47 3626 60 810 Koibatek 6278 10369 165 6192 99 5961 95 5992 95 6094 97 5850 93 5244 84 3338 53 4799 76 4805 77 811 Nandi South 12475 10952 88 10390 83 9690 78 10126 81 9649 77 8620 69 7362 59 1971 16 49 0 4560 37 RIFT VALLEY 328232 267317 81 250553 76 232311 71 254551 78 244437 74 226875 69 192729 59 92630 28 31932 10 160199 49

code District_ 2 3 1 2 3 1 % sles _L1 Fully Immu %Cov Infants YF_L1 VA_L1 %CovYF Surviving DPT1_L1 DPT2_L1 DPT3_L1 CovDPT1 OPV1_L1 OPV2_L1 OPV3_L1 %Cov VA %Cov %CovMea %CovDPT %CovDPT Measles_L %CovOPV %CovOPV %CovOPV FullyImmu 901 Bungoma 53159 41391 78 39616 75 36052 68 39660 75 38020 72 34789 65 31508 59 26835 50 0 0 27404 52 902 Busia 19462 19363 99 17944 92 17052 88 17802 91 17532 90 16907 87 14720 76 6512 33 0 0 12624 65 903 Kakamega 31298 25334 81 23147 74 19798 63 26279 84 24706 79 21790 70 17323 55 12408 40 0 0 15189 49 904 Vihiga 20356 17544 86 16948 83 15849 78 16584 81 16393 81 15207 75 15180 75 13843 68 0 0 14086 69 905 Mt. Elgon 7774 7167 92 6781 87 6102 78 6664 86 6212 80 5540 71 4715 61 4816 62 0 0 3600 46 906 Teso 10137 7105 70 7116 70 6861 68 7149 71 7175 71 6857 68 6093 60 4479 44 0 0 5891 58 907 Lugari 11720 9860 84 9511 81 9145 78 9912 85 10031 86 9168 78 8131 69 4633 40 0 0 7087 60 908 Butere/Mumias 23414 19865 85 18175 78 16170 69 20647 88 18461 79 17694 76 13793 59 7523 32 0 0 10755 46 WESTERN 177320 147629 83 139238 79 127029 72 144697 82 138530 78 127952 72 111463 63 81049 46 0 0 96636 54 National Coverage 1254608 1057981 84 991461 79 938299 75 1027908 82 979381 78 927996 74 813846 65 579958 46 31958 3 724796 58

Annual Report 2003 - 2004 84 Table 57: EPI coverages by district 2003

Code District Name ta. A Fev. Imm. Msles Infants OPV 1 OPV 2 OPV 3 Penta 1 Penta 2 Penta 3 Penta Surviving Vitamin A Vitamin % Cov. Yel. % Cov. % Cov. Full. Yellow Fever Yellow Fully Immun. Fully % Cov.Msles % % Cov. OPV 1 % Cov. OPV 2 % Cov. OPV 3 % Cov. Penta% Cov.1 Penta% Cov.2 Penta% Cov.3 % Cov. Vi

101 Central 9485 7062 74 6397 67 6116 64 6856 72 6345 67 6047 64 6387 67 423 4 0 0 6638 70 102 Kasarani 13683 21831 160 20970 153 19718 144 23107 169 22165 162 21247 155 18889 138 1035 8 0 0 20340 149 103 Westlands 8381 9360 112 8874 106 8504 101 9179 110 8872 106 8472 101 7481 89 997 12 0 0 7476 89 104 Embakasi 17557 17681 101 16198 92 15716 90 18235 104 17452 99 16041 91 15266 87 1073 6 0 0 15233 87 105 Kibera 11576 10640 92 9852 85 8131 70 10511 91 9612 83 9077 78 7625 66 0 0 0 0 7572 65 106 Pumwani 8164 7071 87 6242 76 5633 69 6904 85 6229 76 5684 70 4571 56 815 10 0 0 3720 46 107 Dagoretti 9710 14132 146 12869 133 12300 127 14510 149 12990 134 12732 131 11264 116 655 7 0 0 11081 114 108 Makadara 7971 9332 117 8067 101 7991 100 8481 106 7892 99 7801 98 6800 85 0 0 0 0 5799 73 NAIROBI 86527 97109 112 89469 103 84109 97 97783 113 91557 106 87101 101 78283 90 4998 6 0 0 77859 90 201 Kiambu 26748 21613 81 21434 80 20374 76 21392 80 20924 78 20307 76 18983 71 0 0 0 0 17766 66 202 Kirinyaga 14063 13536 96 13568 96 13378 95 13529 96 13546 96 13368 95 13085 93 1094 8 0 0 13089 93 203 Muranga 10586 9112 86 9131 86 8901 84 9153 86 9345 88 8911 84 8604 81 0 0 0 0 8340 79 204 Nyandarua 18711 17921 96 16933 90 15855 85 17704 95 16897 90 15698 84 15315 82 1490 8 0 0 15074 81 205 Nyeri 20838 17572 84 17377 83 16553 79 17483 84 17411 84 16492 79 16152 78 0 0 0 0 15505 74 206 Thika 23334 21625 93 20862 89 19735 85 21371 92 20765 89 19817 85 19153 82 0 0 0 0 18418 79 207 Maragua 13402 11821 88 12093 90 11196 84 11090 83 11684 87 11199 84 12092 90 0 0 0 0 11741 88 CENTRAL 127682 113200 89 111398 87 105992 83 111722 88 110572 87 105792 83 103384 81 2584 2 0 0 99933 78 301 Kilifi 24846 22873 92 22389 90 20566 83 22033 89 21554 87 20082 81 18868 76 0 0 0 0 18369 74 302 Kwale 23507 21024 89 19898 85 19100 81 20821 89 20432 87 19058 81 18678 79 0 0 0 0 15277 65 303 Lamu 2498 3390 136 3238 130 2984 119 3168 127 2976 119 2742 110 2664 107 254 10 0 0 2413 97 304 Mombasa 27529 22830 83 20667 75 19593 71 21479 78 20167 73 19084 69 16952 62 0 0 0 0 17200 62 305 Taita Taveta 8877 7733 87 7733 87 7156 81 7646 86 7741 87 7199 81 6889 78 388 4 0 0 6755 76 306 Tana River 8093 6328 78 5382 67 4806 59 5848 72 5084 63 4611 57 4938 61 156 2 0 0 3487 43 307 Malindi 13342 13370 100 12170 91 10844 81 12791 96 12107 91 10721 80 9631 72 1143 9 0 0 9436 71 COAST 108692 97548 90 91477 84 85049 78 93786 86 90061 83 83497 77 78620 72 1941 2 0 0 72937 67 401 Embu 9116 8681 95 8674 95 8127 89 8662 95 8692 95 8082 89 7556 83 1110 12 0 0 6916 76 402 Isiolo 4185 3560 85 3396 81 3169 76 3470 83 3078 74 3120 75 2773 66 9 0 0 0 2534 61 403 Kitui 24271 18469 76 17643 73 16751 69 18620 77 17901 74 17200 71 14620 60 834 3 0 0 12183 50 404 Machakos 35953 31102 87 30968 86 30230 84 30491 85 30771 86 29802 83 28801 80 0 0 0 0 26778 74 405 Marsabit 4787 3801 79 3630 76 3082 64 3612 75 3456 72 3017 63 2813 59 192 4 0 0 2254 47 406 Meru Central 14548 13443 92 13375 92 12878 89 13355 92 12928 89 12677 87 12198 84 1407 10 0 0 11975 82 407 Makueni 32558 23945 74 23697 73 22308 69 22608 69 23997 74 22726 70 20900 64 0 0 0 0 17352 53 408 Meru South 6708 6500 97 6207 93 5796 86 6277 94 5987 89 5794 86 5889 88 0 0 0 0 5851 87 409 Meru North 26183 23109 88 21030 80 19579 75 22940 88 21142 81 19056 73 16256 62 313 1 0 0 13388 51

Annual Report 2003 - 2004 85 Code District Name ta.A Fev. Imm. Msles Infants 1 OPV 2 OPV 3 OPV Penta 1 Penta 2 Penta 3 Penta Surviving VitaminA % Cov. Yel. % Cov. % Cov. Full.Cov.% Yellow FeverYellow Fully Fully Immun. % Cov. Msles% Cov. % Cov. OPV 1 % Cov. OPV 2 % Cov. OPV 3 % Cov. Penta 1 % Cov. Penta 2 % Cov. Penta 3 % Cov. Penta % Cov. Vi

410 Mwingi 14217 12505 88 11726 82 10707 75 12139 85 11600 82 11350 80 8567 60 197 1 0 0 6653 47 411 Mbeere 7449 7138 96 7021 94 6772 91 6960 93 6863 92 6642 89 5850 79 0 0 0 0 5599 75 412 Moyale 2148 3363 157 3116 145 2959 138 3397 158 3136 146 2979 139 2511 117 5 0 0 0 2439 114 413 Tharaka 4013 3107 77 3231 81 3050 76 2962 74 3207 80 2968 74 2468 62 0 0 0 0 1494 37 EASTERN 186136 158723 85 153714 83 145408 78 155493 84 152758 82 145413 78 131202 70 4067 2 0 0 115416 62 501 Garissa 10980 12916 118 11511 105 10553 96 12728 116 11123 101 10142 92 12118 110 445 4 0 0 8655 79 502 Mandera 7154 7682 107 7532 105 6455 90 7479 105 7476 105 6447 90 5276 74 0 0 0 0 5083 71 503 Wajir 8435 6627 79 4861 58 4292 51 6451 76 4882 58 4141 49 5823 69 0 0 0 0 4594 54 504 Ijara 2156 1531 71 1168 54 943 44 1433 66 1124 52 872 40 1120 52 91 4 0 0 783 36 NORTH. EASTERN 28725 28756 100 25072 87 22243 77 28091 98 24605 86 21602 75 24337 85 536 2 0 0 19115 67 601 Kisii Central 20630 17658 86 16780 81 15238 74 17789 86 17423 84 16457 80 16262 79 859 4 0 0 13419 65 602 Kisumu 22331 21487 96 18943 85 16451 74 21461 96 19433 87 17431 78 13961 63 0 0 0 0 12225 55 603 Siaya 20618 12740 62 10816 52 9342 45 13867 67 11603 56 10343 50 7484 36 181 1 0 0 4771 23 604 Homa Bay 14302 12018 84 9669 68 8701 61 10467 73 9611 67 8898 62 7248 51 935 7 0 0 6039 42 605 Nyamira 19885 21647 109 20940 105 21075 106 19621 99 20305 102 19724 99 17914 90 2553 13 0 0 16499 83 606 Migori 26420 18091 68 13814 52 11646 44 18046 68 14271 54 11576 44 10505 40 2437 9 0 0 7750 29 607 Kuria 8685 6766 78 5668 65 4728 54 6083 70 5607 65 4553 52 4304 50 676 8 0 0 2977 34 608 Suba 7763 6701 86 5042 65 4479 58 6750 87 5341 69 4488 58 4566 59 426 5 0 0 4166 54 609 Rachuonyo 14613 10306 71 7608 52 6618 45 10057 69 8054 55 6885 47 6025 41 1173 8 0 0 4801 33 610 Gucha 20286 16763 83 15768 78 15406 76 16844 83 16648 82 16456 81 15008 74 3125 15 0 0 13384 66 611 Bondo 12257 8295 68 7107 58 6313 52 7323 60 6400 52 5636 46 5026 41 426 3 0 0 4093 33 612 Nyando 12880 10354 80 8959 70 7458 58 9621 75 8718 68 7355 57 5967 46 669 5 0 0 4684 36 NYANZA 200670 162826 81 141114 70 127455 64 157929 79 143414 71 129802 65 114270 57 13460 7 0 0 94808 47 701 Kajiado 18652 13351 72 11782 63 11570 62 13343 72 12672 68 11271 60 10019 54 0 0 0 0 8237 44 702 Kericho 21551 17401 81 15691 73 14735 68 16859 78 16347 76 15554 72 13818 64 0 0 0 0 10621 49 703 Laikipia 13727 10362 75 10300 75 9866 72 10231 75 9996 73 9846 72 8996 66 1019 7 0 0 7640 56 704 Nakuru 50988 42874 84 39659 78 35032 69 44199 87 43464 85 39441 77 35580 70 2907 6 0 0 27183 53 705 Narok 20476 12540 61 11519 56 10030 49 10007 49 11252 55 10157 50 8346 41 431 2 0 0 5795 28 706 Bomet 18706 10939 58 10996 59 9650 52 10245 55 10377 55 9920 53 9004 48 842 5 0 0 4655 25 707 Trans Mara 8789 9197 105 7514 85 6427 73 8120 92 7723 88 6557 75 5326 61 918 10 0 0 4486 51 708 Buret 14661 14494 99 14009 96 12513 85 14563 99 14627 100 13214 90 11859 81 0 0 0 0 11558 79 801 Baringo 12517 8610 69 8264 66 7537 60 9134 73 9074 72 8430 67 8295 66 856 7 6120 49 6078 49 802 Marakwet 6202 5407 87 5064 82 4560 74 5446 88 5220 84 4608 74 4169 67 439 7 1892 31 3264 53 803 Nandi North 13432 11156 83 10259 76 9185 68 10538 78 10731 80 9568 71 8548 64 165 1 0 0 8191 61 804 Samburu 6817 5713 84 5214 76 4351 64 6133 90 5749 84 4862 71 4366 64 245 4 0 0 4002 59 805 Turkana 12215 12736 104 11291 92 9707 79 11811 97 10847 89 9261 76 8810 72 611 5 0 0 6572 54 Annual Report 2003 - 2004 86 Code District Name ta.A Fev. Imm. Msles Infants 1 OPV 2 OPV 3 OPV Penta 1 Penta 2 Penta 3 Penta Surviving VitaminA % Cov. Yel. % Cov. % Cov. Full.Cov.% Yellow FeverYellow Fully Fully Immun. % Cov. Msles% Cov. % Cov. OPV 1 % Cov. OPV 2 % Cov. OPV 3 % Cov. Penta 1 % Cov. Penta 2 % Cov. Penta 3 % Cov. Penta % Cov. Vi

806 West Pokot 15870 11628 73 10276 65 8670 55 11261 71 10121 64 9139 58 7024 44 1214 8 0 0 5009 32 807 Trans Nzoia 27536 21431 78 18574 67 16121 59 21370 78 20440 74 18006 65 16731 61 0 0 0 0 12461 45 808 Uasin Gishu 27901 26502 95 24944 89 23521 84 25140 90 24161 87 22880 82 19454 70 792 3 0 0 18320 66 809 Keiyo 5929 5794 98 5318 90 5121 86 6137 104 5970 101 5648 95 5558 94 1368 23 3700 62 3266 55 810 Koibatek 5874 6086 104 5820 99 5405 92 6027 103 5961 101 5610 96 5860 100 0 0 5350 91 4846 82 811 Nandi South 13433 8681 65 7913 59 6936 52 9080 68 8768 65 7792 58 6439 48 0 0 0 0 3857 29 RIFT VALLEY 315276 254902 81 234407 74 210937 67 249644 79 243500 77 221764 70 198202 63 11807 4 17062 5 156041 49 901 Bungoma 48904 40314 82 35125 72 28892 59 42206 86 38541 79 33394 68 30888 63 2080 4 0 0 26540 54 902 Busia 18425 17524 95 15352 83 13546 74 16725 91 16225 88 14184 77 12066 65 0 0 0 0 11253 61 903 Kakamega 29083 26449 91 22636 78 19029 65 25675 88 23772 82 20451 70 16680 57 4271 15 0 0 14678 50 904 Vihiga 19497 21009 108 18731 96 16968 87 20596 106 19691 101 18278 94 17172 88 1215 6 0 0 15685 80 905 Mt. Elgon 7783 6978 90 6399 82 5679 73 7061 91 6585 85 5859 75 5393 69 179 2 0 0 4801 62 906 Teso 9952 8566 86 7971 80 7310 73 8225 83 7952 80 7495 75 6689 67 629 6 0 0 6294 63 907 Lugari 10698 9490 89 8343 78 6354 59 8868 83 8590 80 7502 70 6733 63 90 1 0 0 5524 52 908 Butere/Mumias 23169 19623 85 17264 75 14534 63 18642 80 17615 76 14533 63 13186 57 161 1 0 0 10602 46 WESTERN 167511 149953 90 131821 79 112312 67 147998 88 138971 83 121696 73 108807 65 8625 5 0 0 95377 57 NATIONAL 1221219 1063017 87 978472 80 893505 73 1042446 85 995438 82 916667 75 837105 69 48018 4 17062 1 731486 60

Annual Report 2003 - 2004 87 Table 58: Immunization Coverage 2002 Report On Infant Antigens Surviving Infants BCG_1 % Penta_1 % Penta2_1 % Penta3_1 DPT3% OPV0_1 % OPV1_1 % OPV2_1 % OPV3_1 % MEAS_1 % FIC_1 % % FAC.RESP

Central 9,234 5,646 61 6,322 68 5,668 61 9,863 107 4683 51 5920 64 5409 59 5041 55 5710 62 5855 63 122

Kasarani 13,322 13140 99 15629 117 14902 112 14258 107 12762 96 14836 111 14774111 14446 108 11651 87 12038 90 114

Westlands 8,160 6807 83 7180 88 7120 87 6398 78 6248 77 6918 85 6469 79 6527 80 5636 69 5496 67 76

Embakasi 17,093 7305 43 9231 54 8369 49 7986 47 6704 39 8935 52 8345 49 7952 47 698841 7354 43 44

Kibera 11,270 8757 78 8062 72 7426 66 6617 59 7889 70 7806 69 7312 65 6510 58 571351 5585 50 91

Pumwani 7,948 19282 243 5683 72 4945 62 4609 58 19100 240 5097 64 4494 57 3929 49 3391 43 3375 42 125

Dagoretti 9,453 14720 156 12730 135 12111 128 11260 119 13477 143 12593 133 11752 124 11106 117 9423100 9153 97 118

Makadara 7,760 3706 48 5261 68 4931 64 4657 60 3288 42 4688 60 4292 55 4926 63 3909 50 1977 25 71

NAIROBI 84,241 79363 94 70098 83 65472 78 65648 78 74151 88 66793 79 62847 75 60437 72 52421 62 50833 60 88

Kiambu 26,042 23361 90 22246 85 21435 82 20045 77 20898 80 21050 81 20774 80 19642 75 17832 68 15038 58 99

Kirinyaga 13,691 10605 77 12446 91 12508 91 11984 88 9855 72 12481 91 12473 91 11984 88 10520 77 10369 76 96

Murang'a 10,306 9315 90 9158 89 9215 89 9068 88 9133 89 8616 84 9133 89 8909 86 8048 78 7919 77 99

Nyandarua 18,217 17889 98 15724 86 16268 89 14954 82 15201 83 16258 89 16028 88 14740 81 13510 74 12659 69 98

Nyeri 20,287 16544 82 14801 73 14482 71 13564 67 16409 81 14712 73 14271 70 13479 66 13055 64 11399 56 92

Thika 22,718 16012 70 15101 66 14239 63 13321 59 14903 66 14206 63 14037 62 13482 59 12301 54 9854 43 42

Maragua 13,048 11209 86 11872 91 11237 86 10590 81 8998 69 11724 90 11199 86 10507 81 9917 76 6832 52 92

CENTRAL124,309 104935 84 101348 82 99384 80 93526 75 95397 77 99047 80 97915 79 92743 75 85183 69 74070 60 86

Kilifi 24,190 22073 91 21510 89 20615 85 18880 78 14703 61 19922 82 21356 88 19301 80 18191 75 16923 70 94 Kwale 15678 69 14933 65 14129 62 12960 57 9053 40 14960 65 14236 62 13620 60 11437 50 10129 44 128

Annual Report 2003 - 2004 88 Surviving Infants BCG_1 % Penta_1 % Penta2_1 % Penta3_1 DPT3% OPV0_1 % OPV1_1 % OPV2_1 % OPV3_1 % MEAS_1 % FIC_1 % FAC.RESP % 22,887

Lamu 2,432 3295 135 3414 140 3234 133 2993 123 2754 113 3304 136 3212 132 2927 120 2634108 2297 94 63

Mombasa 26,802 12910 48 11347 42 10779 40 10380 39 10406 39 11032 41 10703 40 10278 38 9131 34 9099 34 78 Taita Taveta 8,642 6241 72 6258 72 6215 72 5737 66 5775 67 6130 71 6333 73 5745 66 5131 59 5120 59 24

Tana River 7,880 3536 45 3580 45 2888 37 2670 34 2059 26 3284 42 2930 37 2723 35 2400 30 2088 26 29

Malindi 12,989 13214 102 14064 108 12991 100 12236 94 10715 82 13654 105 13030 100 11994 92 925371 9736 75 251

COAST 105,822 76947 73 75106 71 70851 67 65856 62 55465 52 72286 68 71800 68 66588 63 58177 55 55392 52 64

Embu 8,875 11635 131 10058 113 9558 108 8857 100 11571 130 9901 112 9395 106 8791 99 7813 88 6366 72 101

Isiolo 4,075 3393 83 2956 73 2781 68 2480 61 2658 65 8762 215 2855 70 2430 60 1882 46 1121 28 58

Kitui 23,630 18876 80 18622 79 17749 75 16444 70 12685 54 17435 74 17413 74 15780 67 12461 53 10852 46 113

Machakos 35,004 31151 89 32714 93 32698 93 30617 87 24640 70 32253 92 32135 92 30146 86 26320 75 25612 73 114

Marsabit 4,661 3482 75 3678 79 3428 74 3306 71 2022 43 3485 75 3385 73 3104 67 2620 56 2476 53 107 Meru Central 14,164 14402 102 13394 95 13847 98 13644 96 13011 92 12534 88 13064 92 12651 89 1148881 11115 78 92

Makueni 31,698 23504 74 24004 76 22225 70 21944 69 15136 48 21979 69 22925 72 21434 68 17544 55 16413 52 99

Meru South 6,531 6869 105 6233 95 5894 90 5162 79 6483 99 6194 95 6237 95 5169 79 4581 70 4319 66 94

Meru North 25,492 29849 117 23082 91 20082 79 16815 66 19003 75 23391 92 20290 80 16827 66 11133 44 9829 39 101

Mwingi 13,842 10431 75 11642 84 11093 80 9330 67 7179 52 10354 75 10338 75 9171 66 6862 50 4257 31 95

Mbeere 7,252 5353 74 6198 85 5947 82 5232 72 5410 75 5594 77 5370 74 5317 73 4356 60 3499 48 122

Moyale 2,092 2705 129 2911 139 2849 136 2618 125 2927 140 1214 58 2863 137 2626 126 2011 96 1985 95 125 Tharaka 3045 78 3299 84 3080 79 2655 68 2415 62 3087 79 3008 77 2613 67 1699 43 846 22 82

Annual Report 2003 - 2004 89 Surviving Infants BCG_1 % Penta_1 % Penta2_1 % Penta3_1 DPT3% OPV0_1 % OPV1_1 % OPV2_1 % OPV3_1 % MEAS_1 % FIC_1 % FAC.RESP % 3,907

EASTERN 181,223 164695 91 158791 88 151231 83 139104 77 125140 69 156183 86 149278 82 136059 75 110770 61 98690 54 57

Garissa 10,690 11339 106 11960 112 11479 107 9569 90 12615 118 11867 111 11624 109 9502 89 10095 94 5760 54 85

Mandera 6,965 5355 77 4155 60 3798 55 3917 56 2223 32 4650 67 4294 62 3862 55 3066 44 2705 39 51

Wajir 8,213 4335 53 4469 54 3258 40 2977 36 5369 65 4586 56 3412 42 3032 37 3788 46 3502 43 30

Ijara 2,099 1110 53 1239 59 918 44 632 30 469 22 1049 50 867 41 582 28 694 33 558 27 64 N/EASTE RN 27,967 22139 79 21823 78 19453 70 17095 61 20676 74 22152 79 20197 72 16978 61 17643 63 12525 45 67 Kisii Central 20,086 20614 103 18857 94 17665 88 15929 79 18188 91 19555 97 20470 102 16577 83 14599 73 9057 45 125

Kisumu 21,741 15675 72 14059 65 12502 58 10712 49 10608 49 14110 65 12277 56 9943 46 8189 38 4945 23 70

Siaya 20,074 16389 82 15904 79 14332 71 12096 60 8359 42 12673 63 10563 53 8636 43 9179 46 5984 30 70

Homa Bay 13,925 8395 60 8130 58 6439 46 6077 44 4995 36 7411 53 5702 41 4928 35 4135 30 4547 33 70

Nyamira 19,360 16707 86 16446 85 15847 82 14889 77 10657 55 13768 71 12262 63 10495 54 12497 65 7676 40 61

Migori 25,723 14977 58 14406 56 11320 44 8971 35 8204 32 12671 49 10439 41 8144 32 7819 30 3738 15 78

Kuria 8,456 4838 57 5295 63 4884 58 4212 50 2582 31 4224 50 3588 42 3304 39 2974 35 1271 15 103

Suba 7,558 7964 105 6770 90 4821 64 4215 56 4454 59 5676 75 4470 59 4131 55 4850 64 2978 39 28

Rachuonyo 14,227 8834 62 7806 55 6292 44 5170 36 4302 30 7004 49 5709 40 4462 31 4676 33 2403 17 71

Gucha 19,750 18386 93 16241 82 15997 81 15046 76 15164 77 16624 84 16632 84 14862 75 12875 65 10580 54 103

Bondo 11,934 8355 70 8457 71 6901 58 5799 49 5340 45 7991 67 6778 57 5659 47 5360 45 3638 30 58

Nyando 12,540 7202 57 7112 57 5899 47 4692 37 4310 34 6652 53 5861 47 4729 38 387831 2665 21 62 NYANZA 148336 76 139483 71 122899 63 107808 55 97163 50 128359 66 114751 59 95870 49 91031 47 59482 30 74

Annual Report 2003 - 2004 90 Surviving Infants BCG_1 % Penta_1 % Penta2_1 % Penta3_1 DPT3% OPV0_1 % OPV1_1 % OPV2_1 % OPV3_1 % MEAS_1 % FIC_1 % FAC.RESP % 195,373

Kajiado 18,160 12394 68 12534 69 11573 64 10433 57 9660 53 11544 64 11168 61 9751 54 7883 43 7684 42 124

Kericho 20,982 18498 88 18330 87 17082 81 16063 77 13184 63 14377 69 14736 70 13644 65 14231 68 7747 37 117

Laikipia 13,365 9779 73 10135 76 9588 72 7743 58 6968 52 9565 72 8027 60 7072 53 5928 44 4962 37 82

Nakuru 49,642 41171 83 42266 85 40981 83 37536 76 40825 82 39462 79 39816 80 36092 73 28606 58 23570 47 151

Narok 19,936 10939 55 12491 63 11563 58 11011 55 6953 35 11347 57 11063 55 10383 52 12462 63 7851 39 85

Bomet 18,212 14255 78 12518 69 12144 67 10090 55 8576 47 8810 48 8907 49 9478 52 8718 48 3999 22 68

Trans Mara 8,556 6684 78 6638 78 6011 70 9995 117 3473 41 6569 77 6162 72 5216 61 352141 3563 42 74

Buret 14,274 15721 110 14628 102 14459 101 13677 96 13431 94 13624 95 13920 98 13529 95 1157481 11175 78 106

Baringo 12,187 11180 92 11248 92 10952 90 9645 79 9128 75 10706 88 10374 85 9445 78 9192 75 6105 50 128

Marakwet 6,038 5206 86 5513 91 4851 80 4297 71 3250 54 4958 82 4526 75 3708 61 3552 59 3368 56 60

Nandi 26,156 15243 58 13556 52 12581 48 10388 40 10240 39 13498 52 13812 53 10791 41 10242 39 8325 32 67

Samburu 6,637 6338 95 6129 92 5941 90 5010 75 4345 65 4986 75 4815 73 4033 61 3001 45 2744 41 83

Turkana 11,893 12259 103 11790 99 11085 93 9245 78 9397 79 12464 105 11576 97 10208 86 8919 75 8844 74 36

West Pokot 15,451 10664 69 9507 62 8466 55 6883 45 7345 48 9068 59 8408 54 6834 44 4477 29 3647 24 76

Trans Nzoia27,516 27399 100 21887 80 19488 71 17107 62 17292 63 21364 78 22570 82 20444 74 17082 62 11841 43 88 Uasin Gishu 27,164 20661 76 19016 70 17889 66 15403 57 16232 60 18145 67 17824 66 16218 60 14086 52 8997 33 205

Keiyo 5,773 3908 68 3326 58 3419 59 3165 55 3336 58 3334 58 3411 59 3139 54 292851 1234 21 68

Koibatek 5,718 6045 106 5852 102 5820 102 5520 97 5747 100 5559 97 5651 99 5517 96 4924 86 4089 72 90 RIFT 248344 81 237364 77 223893 73 203211 66 189382 62 219380 71 216766 70 195502 64 171326 56 129745 42 102

Annual Report 2003 - 2004 91 Surviving Infants BCG_1 % Penta_1 % Penta2_1 % Penta3_1 DPT3% OPV0_1 % OPV1_1 % OPV2_1 % OPV3_1 % MEAS_1 % FIC_1 % FAC.RESP % VALLEY 307,660

Bungoma 47,612 34846 73 34585 73 30397 64 24960 52 10173 21 34934 73 28458 60 24443 51 22554 47 18374 39 57

Busia 17,939 16974 95 17655 98 14108 79 11938 67 9902 55 14546 81 12790 71 10613 59 8975 50 8358 47 106

Kakamega 28,316 27052 96 24540 87 21525 76 17630 62 10183 36 22760 80 18997 67 15011 53 13934 49 15240 54 87

Vihiga 18,982 19962 105 20216 106 18232 96 15427 81 10004 53 20071 106 18101 95 14890 78 13045 69 12120 64 100

Mt Elgon 7,578 6056 80 5983 79 5115 67 4785 63 1545 20 5588 74 4945 65 4477 59 3780 50 2414 32 81

Teso 9,689 7353 76 7525 78 6707 69 5718 59 3213 33 7545 78 6733 69 5884 61 4819 50 4843 50 83

Lugari 10,416 6304 61 5894 57 5471 53 4541 44 2940 28 6434 62 6086 58 5387 52 4490 43 3855 37 109 Butere/Mu mias 22,557 17599 78 20124 89 15358 68 13400 59 7707 34 14937 66 11570 51 9428 42 11843 53 7911 35 96 WESTER N 163,089 136146 83 136522 84 116913 72 98399 60 55667 34 126815 78 107680 66 90133 55 83440 51 73115 45 88

KENYA 1,189,6 TOTAL 84 980905 82 940535 79 870096 73 790647 66 713041 60 891015 75 841234 71 754310 63 669991 56 553852 47 82

Annual Report 2003 - 2004 92 4.6.1 Disease surveillance activities

Surveillance is active collection of information for action.

4.6.1.1 Acute flaccid paralysis (AFP)

Kenya established EPI disease surveillance System in the country in 1995 based on the strategies and approach developed by countries that had succeeded in eradicating polio in other parts of the world. Surveillance of other diseases is expected to ride on activities for AFP surveillance. Since 1997 when Acute Flaccid Paralysis (AFP) surveillance was initiated by MoH- KEPI and supported by WHO, Kenya has made remarkable progress with active case surges and improved case detections using standardized case definitions. Kenya has attained stool adequacy of above 80% and maintained annualized detection rate of 1.0 in all provinces. Kenya is working with other countries to ensure the achievement of the global goal for polio eradication by 2008. To attain the global standards set for polio eradication, countries must achieve the following indicators in AFP surveillance;- Detect at least 1 AFP case per 100,000 population in children less than 15 years of age (case detection rate); All AFP cases identified (100%) must be investigated. • 80% of AFP cases must be investigated by collecting two stool specimens within the first 14 days from the date of onset of paralysis and 24 – 48 hours apart (stool adequacy). • 80% of AFP cases investigated must have a 60 days follow-up examination after onset of paralysis. • 80% of the districts must send their monthly routine immunization and disease surveillance reports to the national level on time. Attain • 80% OPV3 coverage in all districts. The following is the number of AFP cases and results of the polio AFP surveillance indicators for the year 1996 – 2004

Table 59: Results of Acute Flaccid Paralysis (AFP) indicators for 1996 – 2004

Indicators (Targets in 1996 1997 1998 1999 2000 2001 2002 2003 2004 parenthesis) AFP cases detected (150) 9 24 125 267 130 240 221 AFP overall detection rate 0.06 0.21 0.94 1.79 2.67 1.99 1.77 (Annualized AFP rate of 1.0) Stool Adequacy (2 stool 11.1 34.6 7.3 31 42.9 67.2 75 Specimens collected within 14 days from date of onset of paralysis at least 80%) Non-Polio Enterovirus 10 14.3 10 9.5 8.9 7.8 Isolation (Non- Polio Rate of 10%) Sixty day follow-up (At least 44.4 38.5 30 46 48.7 48.7 91 80% follow-up of all cases detected and investigated) Timeliness routine reports 23 35 10 10 2 70 65 (80%) Completeness routine reports 70 94 91 71 65 84 84 (80%)

Source: EPI IDSR report

Improvement of AFP surveillance may be attributed to improved support supervision by the WHO Regional Disease Surveillance Officers (DSOs) offering the technical support to provinces and districts, disease surveillance co-ordinators at the province and district levels and community participation. At the health facility level, frontline health workers detect, investigate and report/ notify diseases. Efforts must be made to continue sensitizing them.

Kenya established the National Polio Eradication Certification Committee (NCC) and National Polio Eradication Expert Committee (NPEC) in the 2nd quarter of 2001. The role of the NPEC’s is to scrutinize and classify each AFP cases detected to confirm the case as polio or discard it. The NCC further scrutinizes the cases based on the recommendation of NPEC for consideration and certification of the country as polio free by the year 2008.

Annual Report 2003 - 2004 93 Surveillance for Heamophilus influenza type b (Hib) - Heamophilus influenza type b (Hib) is an important cause of meningitis in children aged between one month and five years. The government of Kenya with the support from GAVI and other development partners introduced the Heamophilus Influenzae B (Hib) vaccine in the routine immunization programme for all children from October 2001. The Ministry of Health established a sentinel site in Kenyatta National Hospital for surveillance of Hib to monitor the occurrence of meningitis in children due to the organism. The purpose of surveillance is to measure the impact of immunization programme against the Hib infection.

Analysis of monthly data and feedback to the districts, programmes, health facilities and other stakeholders will be crucial in the implementation of IDSR; however, the capacity for data managers in the province, National and district levels need to be enhanced. The success of implementation of the strategy and plans in general depends heavily on the ability of these Health management levels to analyze and make inference from the data they collect. Computerized system will make it easier for data analysis at both district and provincial level. Effort should therefore be put on installing computerized systems for data processing at both levels of health management in the country. While these levels should also ensure that analysis of data takes place at all levels of health care and the information is used for decision making in programme management.

4.6.1.2 Measles Surveillance Measles is one of the most infectious diseases known to man kind and remains the leading vaccine preventable childhood killer disease worldwide, affecting over 30 million children and killing about one million. Measles has various complications but can be prevented by routine administration of the vaccine. Some of the complications include:- Blind ness

In June 2002 a second doze to all children less than 15 years irrespective of their immunisation status through a measles catch-up campaign was given. The campaign achieved a national coverage of 98% and this has been appreciated by improved routine coverage of 68%. In Kenya, measles threat has declined with active case based and laboratory surveillance systems in place since August 2002. The main goal for accelerated measles control in Kenya is to reduce morbidity by 90% and case mortality by 95% by 2005. This can be achieved by ensuring that all children receive two dozes of measles cases reported in 2004, only 20 cases were confirmed as IgM positive.

Table 60: showing measles IgM positive cases 2003 and 2004

District 2003 2004 District 2003 2004 District 2003 2004 Bondo 2 0 Mandera 5 0Dagorreti 0 1 Busia 11 0 Maragwa 1 0Bungoma 0 1 Butere/ Mumias 1 0 Nairobi 5 0Turkana 0 1 Embu 2 0 Nakuru 2 1Meru South 0 1 Garissa 2 3 Nyeri 6 1Makadara 0 3 Homa-bay 1 0 Rachuonyo 1 0Mombasa 0 1 Kajiado 2 0 Taita Taveta 1 1Kwale 0 2 Kericho 1 0 Teso 1 0Kisii 0 1 Kisumu 1 0 West Pokot 1 0 Koibatek 1 0 Kakamega 0 1Total 48 20 Lugari 1 1 Kirinyaga 0 1

Annual Report 2003 - 2004 94 Figure 40: Suspected And Confirmed Measles Cases Reported 2003 And 2004

2500

2000 1956

1500 NUMBER 2003 2004 1043 1000 802 815

500

65 20 0 Total IgM +ve cases Total Negative Total Rubella cases 2003 65 802 815 2004 20 1956 1043 TYPE OF RESULTS

4.6.1.3 Maternal And Neonatal Tetanus Surveillance

Neonatal Tetanus is a deadly disease affecting newborns with a case fatality of 70% - 100%. Globally, Tetanus kills 180,000 neonates and 30,000 women every year. The disease is characterized by unhygienic birth practice precipitated by use of unsterilised equipment like Knives, razors etc. that have been contaminated by the toxic tetanus bacteria either during cutting or dressing the umbilical cord after delivery. The current 2004 National Maternal and Neonatal Tetanus (MNT) immunization coverage indicators are at 69%. This is far from attaining 2005 goal to eliminate neonatal Tetanus (less than one case per every 1000 live births in all the districts in the country. Various interventions have been carried out to boost the immunity of CBAW by conducting supplemental immunization activities in high risk districts.

RESULTS OF SUPPLEMENTAL IMMUNIZATIONS:

Table 61: Maternal and neonatal tetanus elimination supplemental

IMMUNISATION DAYS 1ST - 3RD ROUND 2002 - 2004 TARGET Achieved % coverage Round 1& 1st 2nd 3rd 1st 2nd 3rd DISTRICT 2 Round 3 Round Round Round Round Round Round

Mombasa 176,037 192,080 35,752 54,084 124,655 20.3 30.7 64.9 Kilifi 138,723 147,600 58,387 60,521 66,255 42.1 43.6 44.9 Kwale 131,282 137,581 51,585 57,244 111,301 39.3 43.6 80.9 Taita Taveta 65,296 66,113 38,195 41,866 61,082 58.5 64.1 92.4 Malindi 71,893 71,893 25,410 59,666 59,367 35.3 83 82.6 Lamu 18,471 19,256 7,496 9,367 17,716 40.6 50.7 92 Tana River 47,886 49,741 17,553 30,542 47,171 36.7 63.8 94.8

Annual Report 2003 - 2004 95 IMMUNISATION DAYS 1ST - 3RD ROUND 2002 - 2004 TARGET Achieved % coverage Round 1& 1st 2nd 3rd 1st 2nd 3rd DISTRICT 2 Round 3 Round Round Round Round Round Round

Coast Province 649,588 684,264 234,378 313,290 487,547 39 45.1 78.9

Kisumu 129,593 134,827 108,084 64,836 122,010 83.4 50 90.5 Rachuonyo 78,956 83,056 87,707 48,588 68,663 111.1 62 82.7 Nyanza province 208,549 217,883 195,791 113,424 190,673 93.9 54.4 87.5

Busia 96,917 102,703 81,227 63,303 96,892 84 65 94

Western Province 96,917 102,703 81,227 63,303 96,892 84 65 94

National average 955,054 1,004,850 511,396 490,017 775,112 53.5 51.3 77.1

Recommendations:

Ø All women of child bearing age (CBAW) should attend health facilities for screening and vaccination against Tetanus. Ø Educate all mothers/ women in the community on the importance of the Tetanus vaccine. Ø Ensure that pregnant mothers receive at least two dozes of the Tetanus vaccine and encourage young girls to start during their teenage the five (5) TT schedule. Ø Improve on disease surveillance. Ø Report all cases of suspected Maternal and Neonatal Tetanus in your area and ask health workers to investigate all confirmed cases.

4.6.2 Cold chain services

VACCINES AND COLD CHAN REPORT 2002-2004

EQUIPMENT RECEIVED AND THEIR DISTRIBUTION

UNICEF COLD CHAIN SUPPORT FOR THE YEAR.2002 A total of fifty one (51) freezers and forty six (46) fridges were provided to the ministry of health through Kenya Expanded program on immunisation by UNICEF for the support of cold chain system in the year 2002. The distribution of the equipment which was based on merit was as shown below.

Table 62: MF 314 Freezers

District Quantity District Quantity District Quantity District Quantity 1.Siaya 1 7. Meru Centr 1 13. Kirinyaga 1 19. Thika 1 2. Maragua 1 8. Meru South 1 14. Kiambu. 1 20. Gucha 1 3.Malindi 1 9. Meru North 1 15. Embakasi 1 21. Nyando 1 4. Nyeri DVS 1 10.Tharaka 1 16. Kasarani 1 22. Buret 1 5. Machakos 1 11. Migori 1 17. Pumwani 1 23. Busia 1 6. Marsabit 1 12. Turkana 1 18. Kibera 1 24. Kakamega 1

Annual Report 2003 - 2004 96 25. Vihiga 1 Depot 1 34.Garissa 2 39.Lamu 1 26. Mt Elgon 1 30.Eldoret 1 35. Tana River 1 40.Westlands 1

27.Mombasa 31. CVS 36.Marakwet 1 41.Koibatek 1 Depot 1 Nairobi 3 37.Ngara 1 42.Kitui 1 28.Nyeri Depot 1 32. Kwale 1 38.Nandi 43.Nandi North 1 29.Nakuru 33. Rachuonyo 1 South 1 Total 43

The remaining (8) were allocated on emergency and contingency basis. Table 63: RCW 50 EG

District Quantity Distrct Quantity District Quantity District Quantity 1. Wajir 2 9. Makueni 2 17.Marsabit 2 25.Trans Mara 1 2. Maragua 1 10. PGH Nyanza 1 18. Lamu 2 26.Rachuonyo 1 3. Koibatek 2 11. Isiolo 2 19. Turkana 2 27.Nakuru 2 4. Turkana 2 12. Kajiado 2 20. Mwingi 2 5. Bomet 2 13. Busia 1 21. PGH, Nakuru 6. Kitui 4 14. Bungoma 2 Annex MCH 1

7. Uasin Gishu 2 15. Vihiga 1 22. Samburu 1 8. Machakos 2 16. Ijara 2 23. Nyamira 1 24. Narok 2 TOTAL 46

Table 64: Allocation of gas. cylinder unicef support to cold chain (epi-kenya october 2003) COAST No. of No. of Cylinders 3. Kitui 53 7 PROVINCE Facilities 4. Machakos 106 12 1. Kilifi 40 7 5. Marsabit 11 6 2. Kwale 45 8 6. Meru 60 7 3. Lamu 22 8 Central 4. Mombasa 67 6 7. Makueni 74 9 5. Taita 40 8 8. Meru South 34 6 Taveta 9. Meru North 43 7 6. Tana River 30 10 10. Mwingi 44 7 7. Malindi 36 8 11. Mbeere 28 5 EASTERN PROVINCE 12. Moyale 13 4 1. Embu 42 7 13. Meru East 10 4 2. Isiolo 22 6 14. Tharaka 10 4

Annual Report 2003 - 2004 97 WESTERN PROVINCE 9. Rachuonyo 36 6 1. Bungoma 41 7 10. South Kisii 25 5 2. Busia 34 6 11. Bondo 25 5 3. Kakamega 52 7 12. Nyando 25 5 4. Vihiga 40 6 RIFT VALLEY PROVINCE 5. Mt. Elgon 11 6 1. Kajiado 84 10 6. Teso 10 4 2. Kericho 64 8 7. Lugari 20 5 3. Laikipia 32 5 8. Butere 38 6 4. Nakuru 164 15 NAIROBI PROVINCE 5. Narok 38 6 1. (Ngara) 37 7 6. Bomet 28 5 2. Pumwani 23 5 7. Transmara 23 5 3. Makadara 28 5 8. Buret 49 7 4. Embakasi 39 8 9. Baringo 64 8 5. Kasarani 38 8 10. Marakwet 20 4 6. W/Lands 33 6 11. Nandi 28 5 7. Dagoreti 24 5 North 8. Kibera 29 11 12. Nandi 32 5 CENTRAL PROVINCE South 1. Nyeru 71 10 13. Samburu 30 5 2. Muranga 44 7 14. Turkana 38 6 3. Kirinyaga 56 12 15. West Pokot 31 5 4. Nyandarua 58 10 16. Trans 49 7 5. Maragua 36 8 Nzoia 6. Thika 71 10 17. Uasin 86 9 7 Kiambu 67 10 Gishu NYANZA PROVINCE 18. Keiyo 24 5 1. Kisii 50 7 19. Koibatek 25 5 2. Kisumu 43 7 N/EASTERN PROVINCE 3. Siaya 48 7 1. Garissa 23 12 4. Homa Bay 25 5 2. Mandera 12 6 5. Nyamira 68 8 3. Wajir 20 10 6. Migori 56 7 4. Ijara 7 7 7. Kuria 29 5 GRAND TOTAL 3144 547 8. Suba 25 5

Annual Report 2003 - 2004 98 Spare parts procured

SPARE PARTS PROCURED THROUGH G.O.K. FUNDS IN 2003 The following spare parts were purchased through Government funds to enable the technicians at the Central Maintenance Workshop repair the broken down Cold Chain Equipment received from various districts in the country. This was a very small percentage of the annual need and was only used for emergency repairs.

Table 65: GOK Procurement in 2003

ITEM DESCRIPTION QTY @ TOTAL Heating element RCW 30 3,200 96,000 42 EG ITEMDESCRIPTION QTY @ TOTAL Thermocouple 50 3,000 150,000 RCW42EG Igniter cable 4 1000 4,000 Electronic Unit VR50 4 30,000 120,000 Charge Control Unit 4 32,000 128,000 VR50 Fan motor complete 2 5,700 10,400 Refrigerant R12 3 11,550 34,650 Refrigerant R134a 2 10,500 21,000 Compressor Danfoss ¼ 10 16,230 162,300 hp R12 Compressor Danfoss ¼ 10 19,600 196,000 R134a TOTAL 912,350

Annual Report 2003 - 2004 99 TOTAL PROCUREMENT MADE THROUGH Refrigration Oil GOK FUNDING IN THE YEAR 2003 20lts Ksh 912,350 Refrigerant R134a 2 Refrigerant R12 2

Table 66: Spare Parts Procured By Gavi Funds Refrigerant R22 1 (I) PROCUREMNT MADE IN 2003 Evaporator fan motor 3 Condenser fan motor complete with blade TOTAL AMOUNT SPENT FROM GAVI FUNDS 1pc @29,000 IN THE YEAR 2004 Ksh 29,000 377,331.20 Condenser fan motor with blade 2pcs @17,600 4.6.2.1 34,800 TOTAL AMOUNT SPENT FROM GAVI FUNDING IN 2003 SPARE PARTS SUPPORT RECEIVED FROM UNICEF IN 2003/2004 Ksh 63,800 Below is the list of QTY UNIT TOTAL spare parts received COST COST (II) PRCUREMENT MADE IN 2004 through UNICEF (USD) (USD) Condenser fan motor complete support for the Cold Chain System. This 1pc 25,000 25,000 did not represent the Power stabiliser total annual requirement but was 2pcs 10,000 20,000 based on the budget Contactor control line, which UNICEF had allocated in the 1pc 1,500 1,500 year 2002. TYPE OF Fan Motor EQUIPMENT RCW 42 EG 4pcs 10,500 42,000 Cooling Unit 50 300.00 1,500.00 Fan blade Thermo-couple 200 3.50 700.00 4pcs 1,600 6,400 Safety Valve 50 5.00 250.00 o Gas/Electric 50 6.6.00 330.00 Thermostat 2000 –30_ +30 c Thermostat 6 Piezo Ignitor 100 4.00 400.00 Heating Element 100 5.45 545.00 Defrost Tmer BICATTI SIBIR V 170 GE 2 Thermo-stat 20 30.00 600.00 Fan Motors (Gas/Electric) Heater Element 230 50 1.00 750.00 2 V ac Thermostat RT4 Thermo-couple 20 7.00 140.00 Safety Valve 20 10.00 200.00 4 SUN FROST RF- Pressure switch Danfoss Dual VB 134a Electronic Unit 10 125.00 1,250.00 2 Compressor 12V. DC 10 180.00 1,800.00 Pressurec swtch single Thermostat 5 30.00 150.00 3 Door Seal 10 5.00 50.00 Charge Regulator 10 150.00 1,500.00

Annual Report 2003 - 2004 100 MF 304 VEST Starting Device 10 10.50 105.00 FROST Thermostat-Freezer 10 45.00 450.00 Compressor Danfoss 15 125.00 1,875.00 NAPS CFS 49 IS TYPE OF QTY UNIT TOTAL Compressor 5 180.00 900.00 EQUIPMENT COST COST Electric Device 5 185.00 925.00 (USD) (USD) Electronic 5 250.00 1,250.00 Thermostat Starting Device 15 18.00 270.00 Charge Controller 5 335.00 1,675.00 Evaporator 15 40.00 600.00 Ncc 77 Thermostat SOLAR SPARE Filter Drier XH9 20 15 5.00 75.00 PARTS GRS Solar Blocks BP 50 380.00 19,000.00 Alu-Cylinder G 134a 100 30.00 3,000.00 Solar Module BP 30 340.00 10,200.00 920 G Electrolyte725 Lt. 30 24.00 720.00 TCW 1152 J7can FREEZER TOTAL 53,260.00 Compressor FR 10 215.00 2,500.00 G7880

TOTAL COST OF UNICEF SPARES SUPPORT FOR THE PERIOD 2003/2004 $53,260.00

ALLOCATION FOR THE SOLAR SPARES 2004

District Solar Battery and Acid District Solar Battery and Acid arrays arrays 1 Wajir 0 8 12 Machakos 0 6 2 Mandera 0 2 13 Marsabit 2 2 3 Garisa 2 2 14 Makueni 4 2 4 Laikpia 4 2 16 Lamu 0 2 5 Moyale 2 2 18 Trans Mara 2 2 6 West Pokot 0 4 19 Mwngi 0 2 7 Marakwet 2 2 20 Ijara 0 2 9 Turkana 2 2 Total 26 48 10 Isiolo 0 4 Reserve stock 4 2 11 Kitui 4 2

NOTE Other spares are normally issued to the districts only upon request.

CURRENT SPARES STOCK BALANCES AS AT MARCH 2005

TYPE OF EQUIPMENT SPARE PART QTY Burner Housing NIL NO. Door Gasket 292.8510.02 NIL RCW 42 EG Door lid lock NIL Cooling Unit 1 RCW 50 EG Thermo-couple 292.8742.01 5 Cooling Unit NIL Flame failure device 292.2006.01 15 TYPE OF EQUIPMENT SPARE PART QTY Gas/Electric Thermostat 292.9363.000 5 NO. Piezo Ignitor 15 Thermo-couple 292.2006.01 NIL Heating Element 292.9491.41 2 Flame failure device 292.2006.01 NIL Igniter Cable NIL Gas Thermostat NIL TYPE OF EQUIPMENT SPARE PART QTY Electric Thermostat NIL NO. Piezo Ignitor NIL Heating Element 230 VAC 296.9730.02 NIL Gas Jet (Butane 30 mbar) 292.8787.06 NIL Igniter Cable NIL Gas burner NIL Gas Jet (Butane 30 mbar) NIL

Annual Report 2003 - 2004 101 Gas burner 296.0626.10 NIL Electronic device NIL Burner Housing NIL Thermostat 10 Door Gasket NIL Door lid lock NIL SIBIR V 170 GE Thermo-stat (Gas/Electric) 200719904/1 5 Heater Element 230 V ac 173742-24/8 1 Thermo-couple 293149604/2 20 Safety Valve 293165701/5 20 SUN FROST RF-VB 134a Electronic Unit 102 N 3030 2 Compressor 12V. DC BD 2.5 F 10 TYPE OF EQUIPMENT SPARE PART QTY NO. Thermostat 5 Door Seal 10 Charge Regulator GCR 2000M 5 MF 304 VEST FROST Compressor Danfoss 3.6038749 1 Starting Device 2.7078197 5 Evaporator Thermostat 2.7038480 NIL

TYPE OF EQUIPMENT SPARE PART QTY NO. Filter Drier XH9 20 GRS 2.6538053 8 Alu-Cylinder G 134a 920 2.6938034.01 80 G MF 314 VEST FROST Compressor 03.603326 NIL DanfossFR10.GOC Starting Device (Relay) 02.7038050 NIL Starting device 6520004 NIL (Capacitpor) Filter Drier XH9 20 GRS 02.6538053 NIL Thermostat 02.7038480 NIL Thermometer 02.7020037-01 NIL TCW 1152 FREEZER Compressor FR G7880 210.0272.00 NIL Starting Device 291.2087.06 10 Thermostat (Freezer mode) 291.2477.00 NIL Thermostat (fridge mode) NIL Compressor fan motor 4 C/W/F NAPS CFS 49 IS Compressor 57010 5 Electronic Device 57010 0 Electronic Thermostat 57020 5 Charge Controller Ncc 77 59050 3 SOLAR SPARE PARTS Solar Blocks BP S6V350 2 Solar Module BP BP285 4 Electrolyte725 Lt. J7can 2 BPVR50F Charge control unit NIL

Annual Report 2003 - 2004 102 4.6.3 Cold chain maintenance activities

I) Planed preventive maintenance was conducted in the following districts during the year 2003/2004 Trans- Mara District Wajir District Moyale District Lamu District Ijara District Isiolo District Garisa Marsabt Suba Turkana

II) Repair activities carried on cold rooms during the year were as follows. Repair of Nakuru KEMSA vaccine dept cold room Repair of Kisumu KEMSA vaccine dept cold room Repair of Central vaccine deport cold rooms

III) Routine repairs carried in the workshop in 2004 RCW42 EG 35 BP VR 50 2 Sibir 3 Vestfrost MF314 4 Vestfrost SB302 1 Vestfrost MF304 1 TCW 1151 3 TCW1152 2 Electrolux RA1300 1To be converted from kerosene to gas

IV) Training Staff participated in EPI trainings as facilitators whenever there was training. Trained 88 Medical Engineering Technicians drawn from all districts on Cold Chain Maintenance.

CONSTRAINS EXPERIENCED

Spare parts funding is still insufficient and as such the program is always forced to ration issuing of which at times results into high immunization dropouts. New equipment that are being procured have always come without accompanying spares parts as per the recommendations given in the product information sheet by WHO and UNICEF. Most of the equipment in the field are aged and thus need frequent maintenance. Most of the Cold Chain spares are not locally available and thus it becomes a lengthy process to acquire them. Solar spars are quite costly making the maintenance also a costly activity. There is no proper training program for Cold Chain Maintenance Technicians.

RECOMMENDATIONS

There is need for advocacy to consider improved funding for maintenance activities. New equipment that are being procured should always be accompanied with essential spare parts. This should be included as part of the initial cost of the equipment. Aged equipment and those that are non-CFC free compliant need to be replaced with CFC free ones. The government should consider waiving taxes on solar medical equipment and accessories to make it cost effective. It is better to have spares for at least two years period to avoid stock outs during procurements. Engineering technicians training should be part of continuous EPI training to ensure high standard of equipment maintenance through out the country at all levels.

Annual Report 2003 - 2004 103 5. REPRODUCTIVE HEALTH (RH) SERVICES

Reproductive Health services mainly can be subdivided into: · Family Planning and Logistics · Delivery/ maternity services · PMTCT · Training family planning and logistics

Table 67: Family Planning commodities distributed from KEMSA/FP Section in 2000- 2004 Condoms Low Dose Progestin Only IUD Jadelle/ Year Condoms (Male) (Female) Injectables Pills Pills (Copper T) Norplant 2000 70,670,490 - 2,090,500 914,900 421,796 36,570 44,245 2001 53,070,260 2,000 2,832,150 2,067,570 496,990 30,260 24,200 2002 47,546,900 186,360 3,438,075 4,005,910 287,560 28,240 72,855 2003 80,994,700 435,540 4,928,300 2,483,107 37,770 36,959 14,452

2004 95,755,977 619,093 3,884,032 3,593,943 200,000 33,218 17,946

Table 68:Potential CYPs according to distribution IUD Total Condoms Condoms Low Dose Progestin (Copper excluding Year (Male) (Female) Injectables Pills Only Pills T) Norplant Total Condoms

2000 588,921 0 522,625 70,377 32,446 127,995 154,858 1,497,221 908,300

2001 442,252 17 708,038 159,044 38,230 105,910 84,700 1,538,190 1,095,921

2002 396,224 1,553 859,519 308,147 22,120 98,840 254,993 1,941,395 1,543,618

2003 674,956 3,630 1,232,075 191,008 2,905 129,357 50,582 2,284,512 1,605,927

2004 797,966 5,159 971,008 276,457 15,385 116,263 62,811 2,245,049 1,441,924

Annual Report 2003 - 2004 104 PREVENTIVE AND PROMOTIVE SERVICES

6. DIVISION OF ENVIRONMENTAL HEALTH

Vision: The division of Environmental Health shares in the vision of MOH by involving the community members in improving their quality of life through public private partnerships and trainings like participatory hygiene and sanitation transformation.

Mission The division of Environmental Health contributes to the national mission by providing Preventive and promotive health services through innovative environmental sanitation and technologies, Food and water quality control services in the context of social set up of communities of Kenya.

Environmental Health Goals · Promote and improve the living and working environments for all Kenyans. · Make all environmental health services more effective, accessible, visible and affordable. · Restructure the Environmental health division to respond to the political, social and economic changes in society. · Raise a population conscious of environmental health effects and how to minimize those effects on Human health.

Staff establishment

Table 69 : Public Health Personnel by Province 2003

PROVINCE PHOS PHTS Total RIFT VALLEY 372 985 1357 NYANZA 148 361 509 WESTERN 107 272 379 CENTRAL 141 484 625 EASTERN 169 453 622 COAST 140 226 366 NAIROBI 88 39 127 N. Eastern 45 65 110 Total 1,210 2,885 4,095

6.1.1 Staff establishment and transport services

Table 70: Motor Vehicles and Motor Bikes by district 2003

Number of staff population Staff/population PROVINCE District Motorcycles ratio PHOs PHTs Central Kiambu 31 80 2 742,000 1: 6,685 Thika 29 69 1 647,000 1 : 6,602 Nyeri 23 95 2 655,000 1: 5,551 Muranga 12 30 2 351,000 1 : 8,357 Maragua 11 46 2 389,000 1 : 6,825 Nyandarua 18 93 1 466,000 1 : 4,199 Kirinyaga 17 71 2 455,000 1 : 5,171 Total 141 484 12 3,705,000 1 : 5,928

Annual Report 2003 - 2004 105 PREVENTIVE AND PROMOTIVE SERVICES

Number of staff population Staff/population Province District # of cycles ratio PHOs PHTs Eastern Machakos 27 53 1 915,000 1 : 11,438 Makueni 22 59 1 767,000 1 : 9,469 Kitui 18 41 1 517,000 1 : 8,763 Meru Central 16 59 2 500,000 1 : 6,667 Meru North 17 44 1 608,000 1 : 9,967 Tharaka 6 32 1 101,000 1 : 2,658 Meru South 10 27 1 205,000 1 : 5,541 Mbeere 9 15 1 173,000 1 : 7,208 Isiolo 10 20 1 101,000 1 : 3,367 Embu 12 57 1 277,000 1 : 4,014 Mwingi 12 25 1 303,000 1 : 8,189 Marsabit 10 21 1 122,000 1 : 3,935 Moyale 14 6 1 54,000 1 : 2,700 Total 183 453 14 4,643,000 1 : 7,300 Western PHOs PHTs Lugari 7 21 1 217,000 1 : 7,750 Kakamega 14 40 1 605,000 1 : 11,204 Vihiga 19 30 2 499,000 1 : 10,184 Busia 17 46 1 371,000 1 : 5,889 Butere 12 29 1 478,000 1 : 11,659 Teso 6 24 2 171,000 1 : 5,700 Bungoma 25 65 2 878,000 1 : 9,756 Mt Elgon 7 17 2 135,000 1 : 5,625 Total 107 272 12 3,354,000 1 : 8,850 Province District Number of staff Motorbikes population Staff/population ratio Coast PHOs PHTs Mombasa 5 14 0 653,000 1 : 34,368 Mombasa 29 44 Ports 0 Kilifi 22 26 2 555,000 1 : 11,563 Kwale 30 41 0 497,000 1 : 7,000 Tana River 10 32 0 18,300 1 : 436 Taita Taveta 21 29 1 248,000 1 : 4,960 Malindi 10 17 1 28,200 1: 1,044 Lamu 13 23 0 73,000 1 : 2,028 Total 140 226 4 1,419,500 1 : 3,878 Province District Number of staff Motorbikes population Staff/population ratio NEastern PHOs PHTs Wajir 9 13 2 321,000 1 : 14,591 Ijara 3 5 0 Mandera 9 15 1 250,000 1 : 10,417 Garissa 10 26 2 390,000 1 : 10,833 Total 31 59 5 640,000 1 : 7,111

Annual Report 2003 - 2004 106 PREVENTIVE AND PROMOTIVE SERVICES

PROVINCE District Number of staff Vehicles population Staff/population /Motorbikes ratio PHOs PHTs Nyanza Homa bay 17 18 1 316,016 1: 9,029 Suba 7 14 1 170,489 1: 8,119 Migori 17 43 9 563,922 1: 9,399 Kisii 15 52 2 538,616 1: 8,039 Gucha 10 34 2 504,831 1:11,473 Nyamira 12 51 1 545,533 1: 8,659 Siaya 13 25 2 525,910 1:13,839 Bondo 12 16 2 261,518 1: 9,340 Kisumu 12 42 2 552,386 1: 13,152 Nyando 15 19 1 328,491 1: 9,662 Kuria 7 21 0 166,350 1: 5, 942 Rachuonyo 9 24 1 336,372 1:10,193 Kisumu Port 2 2 0 Total 148 361 24 4,810,434 1: 9451

Number of staff Motor Bikes population Staff/population ratio Province District PHOs PHTs Rift Valley Bomet 16 41 1 384,000 1 : 6,737 Buret 17 43 2 317,000 1 : 5,284 Kericho 22 48 2 472,000 1 : 6,743 Nandi S. 17 50 2 582,000 1 : 8,687 Nandi N. 18 46 U/Gishu 29 72 1 617,000 1 : 6,109 TransNzoia 28 71 1 575,000 1 : 5,808 West Pokot 16 30 1 309,000 1 : 6,718 Turkana 18 28 1 447,000 1 : 9,718 Baringo 35 49 2 265,000 1 : 3,155 Marakwet 11 48 1 141,000 1 : 2,390 Keiyo 14 44 2 142,000 1 : 2,448 Nakuru 38 119 2 1,197,000 1 : 7,624 Samburu 11 31 1 142,000 1 : 3,381 Laikipia 9 84 1 323,000 1 : 3,473 Narok 18 41 1 363,000 1 : 6,153 TransMara 16 17 1 172,000 1 : 5,212 Kajiado 12 72 1 405,000 1 : 4,821 Koibatek 20 36 2 138,000 1 : 2,464 Moi University 6 12 1 Lokichokio 1 3 0 Total 372 985 26 5,236,000 1: 3,859

6.1.2 Food Quality Control Services

Food Inspection

The inspections were conducted in various food premises. Most food condemned had decomposed. However, the report by quantity was not available to be shared in this document.

Annual Report 2003 - 2004 107 PREVENTIVE AND PROMOTIVE SERVICES

Table 71: Food Sampling

Food item Reason Result Vienna fortified Wines Checking standards Below Cheers Wine Checking standards Below Sahara fortified wine Checking standards Below Kengu King Spirit Standards Compliance Below Vatican fortified Wines Standards Compliance Below

Table 72: Medical Examination of food Handlers

Place of work Total # workers # Examined # Found fit for work Revenue A in A Commercial food Premises 717 1356 1179 49,300 Learning Institutions 491 519 465 5,100 Health Institutions 176 238 219 300

Table 73: Property Inspection

Type of Premises # Existing # Inspected # Licensed # Closed Retail/wholesale shops 8337 7032 4374 324 Butcheries 1265 1133 857 116 Supermarkets 62 61 61 1 Hotel, lodges and Restaurants 84 123 56 15 Cereal Mills 400 346 300 2 Eating Houses/Kiosks 3457 2724 1896 291 Factories 17 16 17 0 Dairies 26 22 25 0 Bars and Restaurants 841 352 292 50 Bakeries 18 16 13 2 Beer Depots 42 24 30 1 Green Grocers 1784 177 2 0 Open air Markets 54 54 24 14 Fish Stalls 1059 972 111 13 Slaughter Houses/Slabs 411 191 114 11 Cereal Stores 150 127 121 0

Table 74: Approval of Building Plans

Type of Premises # Of Plans Submitted # of Plans approved Residential 120 108 Commercial 118 102 Institutional 27 20

Table 75: Water quality Control.

Water source # Existing #Protected # Not protected Quality Status Acceptable Unacceptable Borehole 1270 707 108 707 89 Springs 1771 814 555 820 431 Wells 2875 1087 614 888 60 Pans 54 5 5 10 0 River 152 0 58 0 153 Dam 61 4 32 4 402 Total 6183 2617 1372 2429 1135

Annual Report 2003 - 2004 108 PREVENTIVE AND PROMOTIVE SERVICES

Roof Catchments 10,900 4796 2702 10316 35 Rock Catchments 12 4 8 4 Piped Scheme 144 52 3 47 4

6.1.3 Waste Management

# Girls Boys No of Pit No of Wcs Remarks Inspected Latrines Nursery 4016 41899 45,939 159 36 Reporting rate and style for Primary 2605 83,421 225,225 960 111 school health needs improvement Secondary 651 56,431 64,284 145 69

Post 31 6,548 8,735 51 39 secondary institutions

Solid waste Solid waste in most cases is handled by either crude dumping or incineration. Only in established municipalities of Mombasa, Eldoret, Kisumu, Thika, Nakuru, Kitale, Malindi and Nairobi that there are organized system of waste management. However even in these municipalities, the recommended standard is not met due to numerous constraints. An emerging problem is the management of plastic wastes that are not biodegradable, made worse by the low density that enable them to be blown by wind.

Liquid Waste Liquid waste management is not yet a big problem except in urban slum settlements. This is partly due to the fact that water supply is inadequate quantities while in rural areas the amount of water per person per day does not amount to large quantities of waste water. School Health School health is given priority due to the fact that school children play a key role in behavior change among population through their own modeling and by passing messages to their peers and parents. The key activities undertaken are inspection of institutions to ensure their sanitary states all times as a reminder to the school children of the state of environmental health and also to ensure control of communicable diseases. The other activity is also to give health talks to the school population on disease prevention.

6.1.4 Law Enforcement

Some districts are more active and use the law to achieve their objective while some don’t. During the year a number of cases were prosecuted and also notices for the abatement of nuisances issued. Some of these notices were not followed and it would be difficult to evaluate the outcome of the nuisances.

Annual Report 2003 - 2004 109 PREVENTIVE AND PROMOTIVE SERVICES

Action Taken Mosquito Food quality Housing and Pollution Total Control and safety Blg Construction Notices Intimation 17 96 20 10 1,133* statutory 2 4 3 0 293* Prosecution 5 52 1 0 100* Convictions 0 0 0 0 43*

* Categorization was not done by all reports thus the total cannot tally.

Vector Control

The major vector of concern is the mosquito. This is because it is a vector capable of transmitting several diseases. Mosquito control therefore does not target any species but the total reduction of mosquitoes is seen as a control measure against a number of diseases. Personal protective measures were encouraged and the personnel of the division in collaboration with other stakeholders distributed nets in all the districts a part from demonstrating use and retreatment process. Insecticidal residual spraying was done in areas which are prone to malaria upsurges. Larviciding was also carried out in areas known to be breeding sites.

Annual Report 2003 - 2004 110 CURATIVE AND REHABILITATIVE HEALTH SERVICES

7. CURATIVE AND REHABILITATIVE HEALTH SERVICES 7.1.1 Orthopaedic technology services

Orthopaedic Technology is a section in the Division of Rehabilitative Health services in Curative and Rehabilitative Department of the ministry of health. The two other sections being: a) Occupational Therapy and b) Physiotherapy. It is charged with the responsibility of providing orthopaedic appliances (orthoses and prostheses) to people with physical disabilities. This service is available at all PGHs, most District Hospitals and a few sub-District Hospitals. The future plans are to avail services at all health facilities in the country. Staff, equipment and material shortages have hindered quality service delivery to patients and clients for a long time.

Performance during the years under review showed a major improvement due to increased supervisory visits to the field and collaboration between the MOH and the Association for the Physically Disabled of Kenya (APDK) starting from 2002.

Table 76: Number of patients and appliances given 2003 / 2004 by clinic/province

Province Health facility Pts attendance Appliances given 2003 2004 2003 2004 Mbagathi D.Hospital 140 182 54 61 Spinal Injury Hospital 123 200 45 51 NAIROBI APDK clinic 1255 1560 421 563 R.P.G.Hospital 95 120 63 75 Eldoret D. Hosp 412 570 125 231 Kapsabet D. Hosp 165 200 72 92 R.VALLEY Kitale D.Hosp 327 350 120 135 Kapenguria Hosp 116 135 42 39 Port Reitz Hosp 1124 1445 500 358 Msambweni Hosp 909 1220 245 281 Kilifi D. Hosp 136 215 75 78 COAST Taveta Hosp 85 56 61 46 Embu P.G.H 156 201 72 95 Machakos Hosp 290 305 120 151 Makindu SDH 146 125 35 47 Meru DH 125 115 60 53 EASTERN Isiolo DH 175 194 69 81 T/Nithi DH 104 97 120 85 Muranga DH 104 -- 32 -- Nyeri PGH 173 210 65 87 Kiambu DH 68 53 42 30 CENTRAL Nyahururu DH 65 74 33 41 Thika DH 153 260 57 94 Ol Kalou SDH 44 21 18 14 Nyanza PGH 295 368 150 234 Kisumu DH 146 203 64 81 NYANZA Homa Bay DH 125 140 42 61 Kisii DH 150 254 66 84 Siaya DH 243 146 132 96 Kakamega PGH 955 1124 210 314 WESTERN Alupe Leprosy Hosp 82 65 79 56 N.EASTERN Garissa PGH 155 148 39 62 Totals 8641 10356 3328 3776

Annual Report 2003 - 2004 111 CURATIVE AND REHABILITATIVE HEALTH SERVICES

7.1.2 Physiotherapy services

Physiotherapy services in Kenya have not been easy. The Ministry of Health is charged with providing adequate effective, diagnostic, therapeutic and rehabilitative services for its citizens. However, lack of adequate manpower modern machines/equipments, inadequate allocation of resources i.e. money and capacity building for the staff has largely contributed to low performance and not meeting the clients needs.

Quite a number of interventions were carried out by the unit and ranged from the Community based Rehabilitation (CBR). Diagnosis of cases and treatment in the facilities and development/supply of appliances. The table below shows the workload of patients seen in our health facilities by Provinces.

Table 77: Clinical (curative) physiotherapy services

Province year Number of Number of Facility Improvement Fund (FIF) – cost sharing in Ksh. Patients treatments Cash collected Invoices Exemptions/ Gross total Waivers Kshs Nairobi 2002 14,159 45,448 199,510 - 63,020 182,530 2003 6,567 20259 222,150 428,730 565,290 1,316,170 2004 23,289 139,945 693,278 - 618,926 2,100,874 Central 2002 53,096 149,917 1,810,155 - 386,160 2196,315 2003 51,806 163,737 1775,725 - 611,100 2385,575 2004 52,397 185,933 2,057,723 611,100 945,787 2,936,880 Eastern 2002 82,703 149,917 1,646,867 576,070 315,290 2,538,225 2003 89,450 163,737 2,132,310 - 577,790 3,382,860 2004 96,345 185,933 1,901,485 1,487,510 647,650 3,956,225 Coast 2002 28,716 82,070 2,367,371 303,700 505,030 3,176,101 2003 36,090 125,175 2,396,455 177,330 523,630 3,119,355 2004 40,756 130,179 2,414,837 722,695 208,525 3,298,297 Nyanza 2002 7,564 11,657 316,355 41,820 72,820 430,995 2003 9,251 40,777 1,176,794 - 189,895 1,214,845 2004 10,254 48,891 1,085,450 246,360 356,030 1,687,840 Western 2002 407 4,181 5,100 - 2,000 7,100 2003 10,802 56,112 1,099,030 - 59,135 1,158,170 2004 22,495 66,644 1,322,475 836,780 74,210 2,203,465 Rift Valley 2002 18,905 44,812 1,27,393 79,160 327,190 1,693,743 2003 20,611 61,256 1,054,120 - 349,660 1,441,220 2004 58,875 114,895 1,783,335 901,610 389,645 3,072,322 N/Eastern 2002 ------2003 ------2004 91 219 117,850 17,750 - 135,600 Total 2002 205,613 446,167 7,552,749 1,000,750 1,671,510 10,225,009 2003 224,573 605,490 9,856,589 606,060 2,876,500 14,018,195 2004 304,502 847,523 11,376,433 4,823,805 3,240,773 19,391,503

· The FIF collections were averagely 59% of the total value due to be collected while average number of treatments given are 3 sessions.

Note: Nairobi Province has 27 physiotherapists. In the past year two clinics were inspected. There is need for additional staff especially in Ruiru, National Spinal Injury hospital (NSIH), APDK and Kibera. Allocations of FIF 25% for the department need to be addressed. Transport for support supervision should be considered if services should be considered if services are to be improved. Equipments supply for Pumwani Maternity Hospital and Ruiru to start outpatient services is needed. In general staff development and training/updates need to be addressed.

Western province has 38 physiotherapists and requires 19 more to be deployed in Namable, Malakisi, Malava, Mt. Elgon and province general hospital, Kakamega need 4 in ICU which is about to start.

Annual Report 2003 - 2004 112 CURATIVE AND REHABILITATIVE HEALTH SERVICES

Eastern province on the other hand has 64 facilities with Physiotherapist units. 23 of the facilities need additional Physiotherapist all totaling to 58. Tharaka district need to open up a department and therefore require adequate space and equipment are a problem in the Province.

North eastern province has 7 Physiotherapists. The region is fast and need more staff. There is great improvement especially where the newly employed team reported.

Finally Nyanza province has 54 physiotherapists, with deficit of 20 staffs. Equipment needs to be addressed as most facilities have either very old or no equipment. Work space in some centres/ districts should be improved. Siaya and Suba districts did not submit any report. While Gucha district started Physiotherapy services at the district hospital it’s expected that reports will start flowing timely in all areas.

7.1.3 Community Based Rehabilitation (Cbr) Community based rehabilitation (CBR) as advocated for by the World Health organization (WHO) was designed to be integrated in PHC activities with emphasis on transferring of basic techniques to grass root implementers including PWDs. In 1994 WHO, ILO and UNESCO issued a joint position paper to remove the confusion, which existed among the different implementers because of the CBR definition. The same authorities have again reviewed this definition in 2004 to make it more current since CBR is a development strategy that is dynamic. Apart from the initial medical care it will include multidisciplinary interventions-medical, social education, vocational and involvement of the service Consumers in implementation (lagerwal: Oppelstrup; Belgrud 1997, CBR joint Position paper-ILO, UNESCO, WHO, -2004).

The concept and principles have tried to address the wider aspects of the CBR approach while the practices is really PHC oriented because of the grass root implementers in the Primary health care programmes. Community involvement, participation and multisectoral approaches have been seen as vital for the implementation of CBR during implementation.

The conventional rehabilitation Services in Kenya have not been able to cope with the Disability needs and requirements due to various reasons;-

1. Lack of proper services 2. Lack of accessible services to PWDs especially in rural areas. 3. Lack of clear structures that enhance provision of quality services 4. Community ignorance on their own potentials in coping with certain disability needs 5. Adverse or absolute poverty at the grass root level 6. Natural catastrophes that interrupt community development cycles e.g. Floods, epidemics, and famine. 7. Inadequate resources and personnel to cope with disability needs at different levels of implementation. (Lagerwal; Oppelstrup; belgrud 1997; Owako 1995).

In Kenya, 70% to 85% of people line in rural areas. The country estimated population was 28.7 Million (CBS- 1999 population and Housing Census). It is estimated that about 2.9 million Kenyans have different types of impairments (WHO standards). It is also estimated that static facilities only cater for between 15% - 20% of the rehabilitation needs of PWDs. This type of service (CBR) delivery system is aimed at:-

· Reaching as many disabled persons as possible · Involving of their families and community members · Focusing on disability prevention and early identification · Involving disabled persons in their own rehabilitation activities. · Putting in place permanent/sustainable systems for rehabilitation needs · Identifying other service providers in rehabilitation.

The likely prevalence of significance in sub-Saharan rural Africa is 6%-8% with about 20% requiring direct rehabilitation (Finkenflugel 1991). However, due to the escalating poverty levels in developing countries these figures could be much higher than what is currently being captured by reports. There is strong linkage between disability and poverty. In Kenya the poverty levels is over 60%.

Annual Report 2003 - 2004 113 CURATIVE AND REHABILITATIVE HEALTH SERVICES

Rehabilitation of People with Disabilities (PWDs) has mainly been through government ministries, private institutions and a few Non-Governmental organizations (NGOs). The ministry of Health started implementing CBR in 1990 through support from SIDA. This was initially piloted in three districts in the western part of Kenya i.e. Siaya, Kisumu, and Nandi and expanded to other districts of Bondo in Nyanza Province, Kajiado in Rift Valley, Machakos, Embu, Tharaka, Mbeere and Meru South in Eastern province.

Disability prevalence in the pilot districts was at 2.2% in Nandi 5.6% in Siaya and 10.2% IN Kisumu respectively during a mid-term evaluation in 1995 conducted by MOH and the funding agency SIDA. The impairments were difficulty in mobility, learning and multiple, behaviour disturbances, seeing, hearing and speech, fits, loss of sensation in the limbs respectively. The prevalence in other districts ranged from 7% to 13%.

The main causes of disability as observed in all districts could be associated with the following:-

· Diseases · Malnutrition · Poverty · Traumas · Idiopathic causes · Low literacy levels

Common causes in children

· Malnutrition · Malaria · Chronic chest conditions · Birth Trauma · Measles · Meningitis · Burns and · Domestic accidents

Common causes in adults

· Road traffic crushes · Assaults · Stroke(Cerebral Vascular Accident – CVA) · HIV/AIDS (leading to brain damage or mental illnesses). · Arthritis

The rehabilitation of PWDs particularly in health sector in Kenya had been conventional up to 1989. The main reason that members of the rehabilitation teams had not been exposed to community based rehabilitation approaches CBHC services and PHC during their under graduate training. Rehabilitation and therapeutic interventions has mainly been institution based. During the year 2001 the WHO supported a study on the situational analysis in a 4 sites in Machakos district Eastern Province. In the year 2003, several districts have been implementing CBR activities however; only 18 districts gave feedback using the monitoring tools.

Annual Report 2003 - 2004 114 CURATIVE AND REHABILITATIVE HEALTH SERVICES

Figure 41: Number of pwds identified in 2003 by gender and age

900 842 818 800 773 742

700 y = -45.6x + 803.6 R2 = 0.1274

NUMBER600 OF PWDs574 543 554 495 500 MALES NO FEMALES NO

400 Linear (MALES NO) 358 352

300

200

100

0 0-5YRS 6-14YRS 15-23YRS 24-49YRS > 50YRS AGE IN YEARS

Source: Division of rehabilitation (CBR) MOH Headquarters 2003

A total of 6,049 clients with disabilities had been identified in the 15 district and benefited different types of health and rehabilitation services during the year 2003.

55.1% (3,333) were males and 44.9 %( 2,716) were females and an average of 504 clients were either identified or attended to on a monthly basis in all the 15 districts that reported. The disability prevalence was highest amongst the males than the females in all the age groups. It was also noted that disability was more common in ages 6-14 years, 15- 23 years and 24 to 49years in both genders while the trend reversed in ages 0-5 years and over 50 years. The table below shows disability prevalence amongst the different age groups by gender in 2003. N=6,051

Table 78: Identified PWDs from 16 districts AGE GROUP MALES FEMALES TOTAL % TOTAL YEARS NO % NO % % 0-5YRS 574 9% 495 8 1069 18 6-14YRS 842 14% 773 13% 1615 27% 15-23YRS 742 12% 543 9% 1285 21% 24-49YRS 818 14% 554 9% 1372 23% > 50YRS 358 6% 352 6% 710 12% 3334 2717 6051 TOTAL 6051 55% 6051 45% 6051 100%

The most prevalent type of disability was noted as Physical handicap, Visual impairment, Hearing and Speech difficulties, Learning difficulty, Fits, Behaviour Disturbances, Loss of Sensation in the hands and feet and multiple disabilities respectively. Fits and behaviour disturbances were noted to be more common amongst the females than males with the highest at the ages from 6 – 14 years. Hearing, speech and multiple disability disorders were also notably significant in all groups.

Annual Report 2003 - 2004 115 CURATIVE AND REHABILITATIVE HEALTH SERVICES

The table below shows the resource persons in CBR programmes. Table 79: Community own resource persons Number of CBR workers Trained Untrained Males Females Males Females TOFs 61 31 39 31 TOTs 278 194 66 50 CHWs/CRWs 861 1817 168 403 FT 185 472 174 279

Types of appliances, assistive devices and supportive devices in use.

A total of 1341 different types of appliances or assistive devices were reported in use in 2003. The proportions are displayed in the figure below.

Figure 42: Proportions of appliances / devices in use 2003 others, 1%

Hearing, 3% Visual, 3%

Hearing Visual Mobility others

Mobility, 93%

The table below shows the number of clients referred for certain interventions or involved in socio-economic activity and those integrated into community development systems by gender in 2003. Table 80: Refered Cases Activity Males Females Total Number of clients involved in socio-economic activity 330 233 553 Number of clients integrated into community development systems 680 694 1,374 Number of clients referred for medical interventions 794 1477 2,271 Number of clients referred for educational integration 478 395 873 Number of clients referred for vocational Training 160 87 247 Number of clients referred for other services 52 60 112

The number of community support groups and organizations for PWDs are still in establishment and therefore not developed. However, a total of 106 community support groups and 93 PWDs organizations have been reported as existing active as by 2003.

The year 2004 was a year of immense difficulty with few CBR and outreach clinic sites reporting. There were no contact follow-ups. The table below shows the cases identified and some of the interventions taken.

Annual Report 2003 - 2004 116 CURATIVE AND REHABILITATIVE HEALTH SERVICES

Table 81: Cases identified and interventions taken by province Province Remarks istricts CBR D Identified cases Referred for interventi ons No.given appliances Economic groups Cases integrated Nairobi 4 2879 143 334 49 All CBR units reported Central 5 2200 0 0 0 0 Nyeri and Maragua reported- Province need follow-up

Eastern 6 12136 2771 248 119 129 Encouraged to keep up with good work.

Coast 5 631 0 0 0 0 Only Mombasa reported but it seems reporting and co- ordination in the province is weak.

Nyanza 5 1822 2249 509 202 Kisumu reported, rest need follow-up, seems problem in reporting and co-ordination in the province.

Western 4 1139 113 253 2 0 Busia and Vihiga reported, need follow-up.

Rift Valley 4 319 306 20 0 0 Nakuru and Trans Nzioa, seems had problem of reporting and co- ordination in the province.

North 1 39 0 0 0 0 Mandera reported. Establishing Eastern and need support.

Total 34 21,165 5,582 1,364 323 178 Need follow-up

Figure 43: % of CBR Districts by province

North Eastern

3%

Nairobi Rift Valley 12% Nairobi 12% Central Eastern Coast Nyanza Western Central Western 14% 12% Rift Valley North Eastern

Nyanza Eastern 15% 17%

Coast 15%

Annual Report 2003 - 2004 117 CURATIVE AND REHABILITATIVE HEALTH SERVICES

Figure 44: CBR and outreach clinic services 2004 reported by province

14000

12136 12000

10000

8000 Identified cases Referred for interventions No. given appliances

NUMBER OF CASESOFNUMBER 6000

4000

2879 2771 2200 2249 1822 2000 1139 631 509 334 248 253 319306 143 0 0 0 0 113 20 39 0 0 0 Nairobi Central Eastern Coast Nyanza Western Rift Valley North Eastern PROVINCE

Inter-sectoral collaboration:

The main inter-sectoral collaborators during the year were:- · Ministry of Education Science and Technology. · Local faith based organizations. · Provincial administration · Department of Culture and Social Services. · Local NGOs · National NGOs · Organizations of PWDs and · Community support groups.

The main activities carried out by reporting districts were: · Capacity building at all levels of implementation. · Identification, assessment and screening on disabilities. · Referral for medical interventions (corrective surgery, medical clinic, physiotherapy, occupational therapy, orthopaedic and provision of rehabilitation equipment. · Carrying out home visits, mobile and outreach community services. · Formation of community social groups · Provision, fabrication and repair of appliances and supportive devices. · Monitoring and supervision · Integration of PWDs into community development activities or systems · Enhance inter-sectoral collaboration and networking. · Initiating socio-economic support to PWDs In most areas where donors have not supported the CBR activities, cost –sharing (FIF) played a major role. Collaboration also with APDK was enhanced and therefore increased coverage on outreach services.

Annual Report 2003 - 2004 118 CURATIVE AND REHABILITATIVE HEALTH SERVICES

Constraints: · Inadequate of funds to run the CBR activities. · Inadequate transport for field work and outreach activities · Lack of adequate skills and knowledge on CBR concept and principles by some implementers at different levels. · A number of districts carrying out CBR activities, poorly report except Eastern province. · Inadequate equipment necessary for rehabilitation · Inadequate supply of consumables for curative, preventive and promotive physiotherapy services · Low literacy levels and cultural barriers amongst communities making implementations difficult · Movement of nomadic groups · Extreme poverty amongst com m unity members complicating service delivery. · Lack of consistency in collaboration by implementing partners · Inadequate submission of reports from districts.

Way forward · Employ more physiotherapist so as to cope with workload · Procure modern machine and materials, equipment and equip the facilities · Develop strategic plan · Network with development partners, PWDs and community support groups. · Develop a common/standardized tool for reporting and ensure that districts report promptly · Provide supportive supervision at all levels · Capacity building to the staff, PWDs and sensitization of the community · Allocate enough resources for purchase of consumables ( materials) for curative, preventive and promotive physiotherapy services · A budget line should be allotted for both clinical physiotherapy and community based rehabilitation

8. Division of Ophthalmic Services

The Division of Ophthalmic Services (DOS) was upgraded from an Eye Programme to a full division in the year 2001. The programme supports 73 eye clinics in terms of provision of drugs and equipment. Currently the division has 57 ophthalmogists, 87 ophthalmic Clinical Ophthalmogists and Cataract surgeons and 2 ophthalmic nurses.

Currently the programme runs thirteen mobile eye units, four of which are supported by Sight Savers International (SSI). The other nine are funded by Operational Eyesight universal (OEU) and Kenya Society for the Blind (KSB).

Drugs supplied to eye units as follows:

DRUGS QUANTITY Prednisolone 0.5% and 1% ……………. .9294 Prednisolone 0.5%/ Gentamicin 0.3%……….28648 Gentamicin 0.3%…………………………….8207 Chloramphenicol 0.5%………………………7429 Amethocaine 0.5%…………………………1279 Cyclopentolate 0.5%…………………………1246 Mydriatic cocctail………………………………3122 Fluorescesis strips 1 drops……………………..609 Piloccirpine 2% and 4%………………………3299 Atrpine 1%……………………………………1693 Zinc sulphate 0.25%…………………………...6348 Hydrocortisone 1%…………………………….6911 Methylcellulose 2%……………………………1281 Poridone iodene 1%……………………………1770

The production output was lower than other years as raw materials ran out of stock and the Unit was closed for months awaiting supply of raw materials.

Annual Report 2003 - 2004 119 CURATIVE AND REHABILITATIVE HEALTH SERVICES

COMPARISON ANNUAL EYE MORBIDITY STATISTICS FOR 2000 TO 2004

Table 82: Summary data for the years 2000-2004.

Comparison performance of four years 2000 2001 2002 2003 2004 New Patients 288,068 349,805 339,675 327173 395,672 Revisits 101,128 138,412 126,384 148,835 144,885 SUB-TOTALS 389,196 488,361 466,059 478,835 540,557 Visual Acuity ( Better Eye ) - all patients Children ( < 5 years ) 23,894 25,407 34,204 48,160 46,634 Normal (> 6/18 ) 132,857 170,422 123,337 224,169 223,643 V A Loss ( < 6/18 ) 32,142 31,607 38547 50,384 55,416 Blind ( < 3/60 ) 19,986 21,821 23,863 38,558 39,645 Blind NPL 2,106 2,542 3,952 7,687 11,405 Clinical Diagnosis - All Patients Normal 17,188 36,732 34,247 37,390 Cataract 32,654 48,040 40,893 39,478 44,926 Glaucoma 6,344 8,609 8,081 7,724 10,546 Strabismus / Amblyopia 2,112 2,644 2,427 2,452 3,728 Presbyopia 23,434 24,831 23,433 24,411 24,253 Other refractive errors 32,908 46,729 43,292 45,663 47,621 Active Trachoma 4,039 15,212 13,721 12,456 7,475 Inactive trachoma- (Trichiasis /Entropion) 4,447 4,284 3,893 4,221 4,533 Corneal scar- Trachoma 2,883 2,445 3,072 3,402 2,952 Corneal scar- injury or Infection 6,376 37,188 6,297 6,899 6,885 Purulent Conjunctivitis 23,529 48,040 23,733 26,799 22,940 Allergic Conjunctivitis 81,325 8,609 90,041 108,655 114,810 Ophthalmic Neonatorum 1,999 2,644 1,647 1,790 2,192 Active Corneal Ulcer 4,650 24,831 5,397 6,786 7,964 Optic Atrophy ( non-glaucoma ) 1300 46,729 1,777 1842 2,295 Xerophthalmia 3,860 15,212 2,240 1842 1,437 Retinal Disease 2,054 3,337 3,095 3298 4,830 Macular Degeneration 1,904 2,333 2,962 3,341 3,524 Injury 10,768 11,162 10,981 12,096 14,166 Uveitis ( Anterior ) 5,012 5,898 6,392 7,391 8,612 Chalazion / Stye 10,523 10,313 9,905 10,744 11,192 Pterygium 5,254 6,362 7,749 6,337 7,328 Retinoblastoma 258 317 333 358 367 Herpes Simplex 2,498 2,352 2891 2,971 3,027 Others 38,560 64,807 61,032 68,973 82,438 TOTAL DIAGNOSIS 315,691 444,349 412,116 444205 477,317 Surgery Performed Cataract 12,631 16,812 20,659 21,251 22,567 Glaucoma 714 810 689 1,007 791 Perforated Injury Repair 709 598 663 780 1,064 Enucleation 223 159 172 258 267 Entropion 1,333 1,019 1,436 1,860 1,318

Annual Report 2003 - 2004 120 CURATIVE AND REHABILITATIVE HEALTH SERVICES

Comparison performance of four years 2000 2001 2002 2003 2004 Chalazion/stye 13,336 3,048 3,054 2,844 3,468 Pterygium 656 798 610 876, 1,209 Retinal Detachment 205 117 138 117 94 Corneal Graft 69 89 64 69 70 Squint 63 69 59 144 97 Lid 615 513 462 443 652 Orbital 50 134 56 62 84 Lacrimal 82 190 230 196 258 All Other 3,184 5,640 4,496 3,845 5,236 TOTAL SURGERY 23,890 29,996 32,784 34,258 37,175

Resources available

(a) Vehicles – 14 (fully KSB supported) (b) Motorbikes – 5 (Fully KSB supported)

(C) Financial allocation and expenditure. Allocation Expenditure Donor – SSI (Sight Savers International 13,103,213 13,605,451 GOK - MOH 1,575,000 1,575,000

List of donors and support given to division

Ø Kenya Society for the blind Ø Co-ordinate funding from other donors Ø Provide logistics Ø Provide low cost eye drops Ø Support Lodwar Mobile activities Ø Purchases equipment and Surgical Instruments Ø Manages SSI Funds and Vehicles on behave of MOH

Ø Sight Savers International -

· Supports 4 mobile Vehicles, 1 PEC and 1 Co-ordinating Vehicles · Supports Eye Units and Clinics within Machakos and Nakuru zones · Has build Eye units at ; Nakuru, Machakos, Mbagathi ,Kakamega, Eldoret,and Kisumu · Supports two comprehensive Eye service Projects at Kericho and Mbagathi (Nairobi) Overseas eye sight universal · Supports eye units and Clinics in Nyeri, Kakamega, Narok, Mombasa, Marsabit, Kapenguria,Samburu and Embu · Supports National eye production unit

Salus Oculi · Have built two eye units at; Kisii and Isiolo · Have provided a Mobile Vehicle for Isiolo unit

Christofel Blinden Mission · Have built Garissa Eye Clinic · Does Mobile Clinics in Northern Kenya · Supports Kikuyu and Sabatia Eye Hospitals Department of Ophthalmogy Nairobi.

Annual Report 2003 - 2004 121 CURATIVE AND REHABILITATIVE HEALTH SERVICES

6. Lions club · Have built Kericho and Kisumu eye units · Give free eye services · Eye hospital Roresho · Eye hospital Mombasa

Constrains · Most existing eye clinics lack diagnostic instrument and ophthalmic surgical equipment. Also some donors who were supporting mobile clinics pulled out.

Way forward for the division · The Kenya Ophthalmic Programme intends to promote and provide · Eye Care Services with the aim of reducing avoidable blindness.

Table 83: Ophthalmic programme progres Targets for the year Progressing achievements of output Issues/comments targets To screen and treat patients in rural through static and 182,258 were screened and treated Mobile clinics reduced mobiles –270,000 patients To provide support to ophthalmic clinical officers 13-oco/cs were supported during their Was done students in KMTC field work To provide support to ophthalmic post graduate 5 students Doctors Was done student doctors in UON PEC sensitization work shops Traiming. DHMT-Nakuru Training’s were done -Mwingi RHWs-Baringo -Mwingi Community Health Workers Training. 2458-CHWs were trained. Was successfully done Refraction training workshop-20oco/nurses Was not done There was no trainer Planning workshop KNOW/Vision 2020 National Was successfully done planning w/shop for eye care -Kabarnet Trachoma planning w/shop OSEA Conference 9 –participants attended 6 attended Trichiasis training workshop The 9 were trained Was done -10 oco/nurses Cataract surgery activities –UON 500, KMTC 150, Is a continuous process Nakuru 800 and Machakos 800-2,250 cases Kenya ophthalmic co-ordination visits 11-districts were visited 15 district were visited To provide tetracycline ointment tubes to trachoma 10,000 tubes were supplied. Comfortably provided endemic areas- Support outreach services to needy areas- 4 vehicles were doing the out reach Services provided services. Ophthalmic equipment assorted – Primary and Few facilities were given Tertiary eye units Ophthalmic equipment – KMTC/UON elective term Were issued. centres

Annual Report 2003 - 2004 122 CURATIVE AND REHABILITATIVE HEALTH SERVICES

9. Mental health services

9.1.1 Introduction

A Division of Mental Health was created on 7th September 1987 and the Director of Mental Health was appointed to head the division and housed within Afya House in the Ministry of Health Headquarters as per recommendations of the GOK – WHO inter-country workshop on mental health held in Nairobi in 1985. The workshop recommended that a specialist psychiatrist at the level of Senior Deputy Director of Medical Services (SDDMS) be appointed to head the created Division of Mental Health within Ministry pf Health Headquarters. The Division of Mental Health was charged with the responsibility of urgent revision of the Mental Health legislation the Mental Treatment Act-1949, Cap. 248 which culminated in its repeal in parliament and the enactment of the current mental health legislation – The Mental Health Act – 1989, Cap. 248 of the Laws of Kenya. The Act created the Kenya Board of Mental Health at National level under section 4 (1) and District Mental Health councils at district level under Section 7 (1)

The essence of all these was decentralization of mental health services and integration of mental health care services within general health care delivery system at all levels.

Mandate To ensure the provision of quality promotive, preventive, curative and rehabilitative mental health care services to all Kenyans by developing appropriate national mental health policy, national mental health strategic plans, national mental health legislation, national mental health programmes of actions and mental health services. Functions · Co-ordination of mental health services in the country · Developing and reviewing national mental health policy · Developing and revising mental health guidelines and standards for mental health care services · Developing and revising mental health legislation · Capacity building of human resource development and training of mental health personnel · Administration and implementation of the Mental Health Act · Collaboration with other key sectors in mental health · Decentralization and integration of mental health care services with general health services · Monitoring and evaluation of mental health care services in the country

Responsibility · Promotion of good mental health · Protection of good mental health · Prevention of mental disorders and substance abuse · Treatment of mental disorders, control of substance abuse and treatment of drug dependent persons · Rehabilitation of mentally ill people and drug dependent persons

Vision Create an enabling environment for the provision of equitable and sustainable quality mental health care that is acceptable, affordable and accessible to all Kenyans.

Mission To provide quality promotive, preventive, curative and rehabilitative mental health care services to all Kenyans.

General Objectives

1. To reduce the incidence and prevalence of specific mental disorders in the general population. 2. To reduce the mortality associated with specific mental disorders both from suicide and physical illness. 3. To reduce the extent and severity of problems associated with specific mental disorders. 4. To ensure that appropriate care services are provided to address mental health problems with a “basket” of essential health and social services. 5. To reverse people’s negative perceptions of mental disorders. 6. To continue research into the causes, consequences and care of mental disorders.

Annual Report 2003 - 2004 123 CURATIVE AND REHABILITATIVE HEALTH SERVICES

Specific Objectives

1. To provide comprehensive mental health care services 2. To integrate mental health programmes into primary health care (PHC) activities. 3. To train adequate mental health personnel. 4. To ensure equitable access to mental health care services. 5. To increase the annual health budgetary allocation for mental health. 6. To develop effective mental health management information systems. 7. To develop mental health education programmes. 8. To encourage and promote effective collaboration and partnership with all mental health stakeholders. 9. To ensure advocacy for mental health among all stakeholders.

GLOBAL VIEW ON MENTAL HEALTH

World Health Organization (WHO) in its constitution defines Health as a “state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity (WHO 1948). The same definition is used in the preface of Kenya’s Health Policy Framework of November 1994 as the guiding principle. However, over the years, not much attention has been given to importance of mental health in the development of Health Policies, health strategic plans, and programmes in member states of WHO to provide quality health care services at all levels of Health Care delivery systems. Indeed, mental, social and physical health really, are inseparable and complementary to one another and therefore mental health is an essential and integral part of health as stated in the definition of Health by WHO.

In the World Health Report 2001, the WHO made a comprehensive review on mental health whose theme was “Mental Health; New Understanding, New Hope”. The Director General’s message had a simple message to member states: Mental health – neglected for far too long – is crucial to the overall well-being of individuals, families, societies and countries and must be universally regarded in a new light.

The Report stated that 450 million people alive today suffer from mental disorders and psychosocial problems such as alcohol and substance dependence and the majority of them suffer silently. One person in every four will be affected by a mental disorder at some stage of life. Major depression is the leading cause of disability and ranks fourth in the ten leading causes of the global burden of disease and is projected to be ranked second within the next 20 years. At least 10 million people attempt suicide every year and one million of them – including many who are very young do kill themselves.

The World Health Report 2003 by WHO states that mental, neurological and substance abuse disorders are a major contributor of the overall Global Burden of Disease (GBD). Globally, 13% of overall disability – adjusted life years (DALYs) and 33% of overall years lived with disability (YLDs) are attributable to mental disorders. A large proportion of individuals do not receive any health care for their condition because the mental health infrastructure and services in most countries are grossly insufficient and very insufficient funding and implementation of programmes largely due to prevalent stigma and discrimination of patients requiring the services.

During its forty-ninth session, the WHO Regional committee adopted the Regional Strategy for Mental Health 2000- 2010 and made resolution AFR/RC49/R3 requested member states to provide financial resources to implement the improvement of quality of life of their people by promoting health lifestyles, and preventing and controlling mental, neurological and psychosocial disorders which include substance abuse. Research done in Kenya indicate that, on average, 25% of those who attend general out patient clinics in all our health care facilities suffer from mental disorders and the vast majority suffer from minor mental disorders such as anxiety and depression.

STATISTICS

GLOBAL Research so far done in different parts of the world and in different communities both in developed and developing countries indicate that mental health problems and mental disorders are ubiquitous. Mental and behavioural disorders affect people irrespective of their sex, age, race, ethnicity, culture, religion or educational as well as socio-economic status in the society.

Annual Report 2003 - 2004 124 CURATIVE AND REHABILITATIVE HEALTH SERVICES

Mental disorders affect adults as well as children. On average, studies done on populations globally yield the following prevalence rates of mental disorders.

· Children under 5 years (pre-school) age – 3% · Children between 6-10 years (primary school) age – 5% · Children between 10-15 years (secondary school) age – 10% · Adolescents – 15% · Adults – 12%

KENYA The prevalence rate of mental disorders in Kenya is similar to other countries. Research so far done in our health care facilities indicate that between 20-30% of all outpatients seeking medical attention in both public and private institutions suffer from mental disorders the vast majority of which are minor in nature. However, most of them are misdiagnosed due to their presenting with predominantly physical symptoms. Most of them are diagnosed and treated for “Malaria”, “Typhoid”,”amoebiasis”, etc leading to drug resistance due to repeated treatments in different health institutions.

MENTAL HEALTH IMPACT ON SOCIO-ECONOMIC DEVELOPMENT

Mental disorders place enormous burden on the patient, the family and the nation the world over. The economic impact of mental disorders is wide-ranging, long lasting and large. Measurable causes of economic burden include health and social services needs, impact on families and care givers (indirect costs) lost productivity, lost employment, public safety, crime and premature death.

Mental disorders are a major contributor to poverty in our society. This is due to the lost production from people with mental illnesses who cannot work or who are ill but remain at work. There is lost production from care givers of people with mental illness and support of dependants of a mentally-ill person. There is lost production from premature death due to suicide. Mental illnesses directly cause poverty and vice versa. Therefore there is need to develop effective mental health care services as part of socio-economic development strategy.

For Kenya to realize its Poverty Reduction Strategy Programme Goals, National Economic Recovery Plan and to spur national motto of a working Nation, it is imperative that adequate resources are allocated to improve the mental health of all wananchi by promotion of good mental health, prevention of mental disorders and substance abuse, control and treatment of mental disorders and substance (drug) and alcohol dependence and rehabilitation of mentally-sick persons and drug-dependent persons. In line with the Health Sector Policy of decentralization of health services and integration of health care services, mental health will be decentralized and integrated within general health care service delivery system so as to be accessible to individuals at Primary Health Care level. Each District is supposed to establish mental health unit to offer comprehensive mental health care services.

Improvement of mental health of mentally-ill persons in particular and the general population in general will enhance the nation’s achievement of national and international obligations set out in different declarations, treaties and conventions. A good example is health seeking behaviour, life styles and positive altitudes which are attributable to good mental health. This helps to prevent the global pandemic of HIV/AIDS which is a national disaster and a great drainage of our meagre resources including human beings.

In order to achieve the Millennium Development Goals (MDG), we require to improve our mental health so as to alleviate poverty and reduce mortality rates by influencing the health seeking behaviour of mothers in particular and general population in general.

In order to improve the quality of mental health care services available, more financial resources are required. These resources will be utilized to train more mental health workers such as psychiatrists, psychiatric nurses, psychiatric social workers, Occupational Therapists and clinical psychologists who are very few at the moment. The other priority area is establishing mental health units in every district to cater for admission and treatment of patients with mental disorders and drug dependence. The other priority is procurement of psychotropic drugs for both outpatients and inpatients. Supervision, monitoring and evaluation of mental health services at all levels is critical. The indicators include the national suicidal rate, the number of districts with established mental health units and the proportion of population with access to quality mental health care services.

Annual Report 2003 - 2004 125 CURATIVE AND REHABILITATIVE HEALTH SERVICES

SUBSTANCE ABUSE IN KENYA

A National Baseline Survey on substance abuse among the youth in Kenya was released in 2004 and shows the following:

1. Substance abuse is widespread, affects the youth mostly but cuts across all Social groups.

2. Alcohol, tobacco, bhang and miraa are the substances most often used.

3. The youth are more and more abusing imported, illegal substances such as heroin, cocaine and mandrax.

A study on the assessment of the linkages between drug abuse, injecting drug abuse and HIV/AIDS in Kenya, was conducted by the United Nations office on drugs and crime (UNODC) and released in June 2004 during the international day against drug abuse and illicit trafficking. The study shows there is a linkage between drug abuse and HIV transmission (Drugs abuse and HIV/AIDS) and a dangerous duo for the country.

9.1.2 Mental health care services

HISTORY OF MENTAL HEALTH SERVICES

1900 – A small pox centre was established where Mathari Hospital now stands. This was in an attempt to deal with the epidemic. 1910 – Smallpox epidemic contained. Facility converted into Nairobi Lunatic asylum. 1924 – Name changed to Mathari Mental Hospital. 1949 – Mental Treatment Act enacted by the colonial government. 1964 – Name changed to Mathari Hospital. 1982 – Mental Health adopted as the 9th element in PHC. 1987 – Division of Mental Health created within MOH. 1989 – MHA, KBMH, District Mental Health Councils. 1991 – Implementation of MHA. 1996 – The first National Mental Health programme of Action was implemented.

HEALTH CARE FACILITIES. Specialized mental health care services are offered in Mathari Hospital which is the National training, teaching, research and referral Hospital. However, we have Psychiatric Units in the Provincial General Hospitals and a few districts.

A psychiatric unit is a ward within the hospital which admits psychiatric patients. Most of these wards are old and dilapidated and require urgent repairs.

PSYCHIATRIC UNITS.

PROVINCIAL LEVEL . There are 22-bedded Psychiatric Units in all Provincial General Hospitals except in Nairobi and North-Eastern Provinces. However, these wards are congested and most of the time admit patients twice their bed capacity. The units are in;- · Embu Provincial General Hospital. · Coast Provincial General Hospital – (Port Reitz Hospital). · New Nyanza Provincial General Hospital – (Kisumu District Hospital). · Nakuru Provincial General hospital. · Nyeri Provincial General Hospital. · Kakamega Provincial General Hospital.

Annual Report 2003 - 2004 126 CURATIVE AND REHABILITATIVE HEALTH SERVICES

DISTRICT LEVEL. There are Psychiatric Units in the following district hospitals · Machakos District Hospital. · Meru district Hospital. · Kisii District Hospital. · Eldoret District Hospital. · Muranga District Hospital. · Isiolo District Hospital. · Siaya District Hospital. · Kerugoya District Hospital.

The long term goal is to have every district establish a psychiatric unit within the district hospital to cater for admission of mentally-sick patients who require inpatient treatment. It is important to note that all hospitals are gazetted, in accordance with section 9 of the Mental Health Act, as mental hospitals for inpatient treatment of mentally-sick patients. In fact patients who require inpatient care are admitted in general wards in hospitals which do not have psychiatric units (Psychiatric Wards) Outpatient Psychiatric services are offered in all health facilities including hospitals, health centers and dispensaries. Overview issues on mental health in general FACTS

1. Mental affect people irrespective of: · Age · Sex · Race · Culture · Ethnicity · Religion · Social status 2. One out of 4 persons will be affected by mental health problems at some stage in their life. 3. Major depression ranked fourth in the leading causes of global burden of disease. 4. At least 10 million people attempt suicide every year. 5. In Kenya, mental disorders are often treated as malaria, typhoid or amoebiasis. This has social economic implications. 6. Mental Health is integral component of general health. There is no health without mental health. ”Sound minds should occupy sound bodies”. 7. Many mental health problems can be prevented. Prevention is better that cure. There is the role of “nature” and nurture. 8. Treatment and cure is available for many mental health problems, including:

· Anxiety disorders · Depressive disorders · Somatoform disorders etc

9. Chronic mental health problems can be controlled and managed to ensure rehabilitation of those affected into the mainstream of society. 10. A Holistic approach – The Biopsychosocial Model is useful in the management of all mental health problems. Everyone has a role to play.

MYTHS 1. Mental Health disorders are caused by supernatural powers e.g. evil spirits and gods. 2. Those who develop mental disorders do so to atone for sins committed by the clan against the ancestors. 3. Witchcraft, curses, demon possession as cause of mental illness. 4. Mental disorders are not treatable. Once affected your are condemned for life.

Annual Report 2003 - 2004 127 CURATIVE AND REHABILITATIVE HEALTH SERVICES

HUMAN RESOURCE

There is an acute shortage as indicated below. · Psychiatrist – 50 · Public Sector – 15 · University – 13 · Private Sector – 20 · Armed Forces – 2 · Psychiatric Nurses – 12-- - 509 in GoK · Social Workers – 80 – 26 in GoK · Occupational Therapists – 500 – 270 in GoK · Clinical Psychologists – 3 – 0 in GoK · Kenyan population – 32 million

Training of mental health workers is being intensified at the University of Nairobi.

· The issue of stigmatization has not been resolved. · The way forward is to integrate mental health into the general health care systems. This should be through concerted effort.

Table 84: Personnel requirement

Cadre No. per province x8 No. per district x70 Grand Total 86 16 70 Psychiatrists 32 280 312 KRPN 598 48 560 KEPN 32 210 Occupational 242 Therapist 16 280 Medical Social 296 Worker 8 140 Clinical Psychologist 148

Mental Health Team

The health professionals involved in the delivery of mental health services include:-

· Psychiatrists · Psychiatric nurses · Clinical psychiatrists · Psychiatric Social Workers · Occupational therapists

Annual Report 2003 - 2004 128 CURATIVE AND REHABILITATIVE HEALTH SERVICES

Future plans

To have mental health where it belongs: at the centre not the periphery of general health

· Proper inclusion of mental health in the NHSSP. · Decentralization and integration. · Proper funding. · Realization of the vision “to create an enabling environment for the provision of equitable and sustainable quality mental health centre services that is acceptable, affordable and accessible to all Kenyans and our mission which is “To provide quality promotive, preventive, curative and rehabilitative mental health services to all Kenyans.

Then it is important to echo the words of WHO in their 2001 World Health Day cerebrations. The director mental health dream is that one day (in the very near future) mental health will be at the top but not beneath. Have his Dream with him!

ACTIVITIES DURING THE YEAR 2003

A TRAINING OF COMMUNITY HEALTH WORKERS IN MENTAL HEALTH

The Division of Mental health undertook a programme to train community health workers in seven districts in the year 2003. Although all the identified districts were not covered (Nakuru, Garissa and Kiambu), four districts and the response was very encouraging. The training were sponsored by the World Health Organization (WHO). The districts covered were Kilifi, Machakos, Siaya and Bungoma.

The objective of the training was to empower community Health Workers with basic mental health information that will enable them promote, prevent and intervene in issues related to mental health.

B STRATEGIC PLANNING FOR MENTAL HELATH

The Division participated in the National making of the National Health Sector strategic plan NHSSP (2005-2010). The Division was represented in all three thematic groups involved in the planning which were:

· Organizational structure · Essential packages · Monitoring and Evaluation

Input was given on mental health issues and it is hoped this will be addressed and will bring a positive impact in the area of mental health.

C MENTAL HEALTH POLICY WRITING

The Division of Mental Health has been involved in the development of a National Mental Health Policy.

A stakeholder’s workshop on the policy took place in September, 2003 and policy writing in December, 2004.

D NAIROBI INTERNATIONAL ASK SHOW The Division of Mental Health participated in this year’s ASK show. The aim of the show is to create awareness in the area of mental health and to help reduce stigma attached to mental illness.

Annual Report 2003 - 2004 129 CURATIVE AND REHABILITATIVE HEALTH SERVICES

SOCIAL REHABILITATION IN MENTAL HEALTH

Social Rehabilitation services are meant to cater for patients who have psychosocial needs in our health facilities and in our communities. This has been possible to some extent with the few medical social workers in the service. Currently there are psychiatric units without social workers and even in the general hospitals, the need is great. Patients suffering from other stigmatized conditions such as HIV/AIDS and TB need the same services. There is an shortage of the personnel to be deployed in all the health facilities.

In terms of the scheme of service for Social Medical Social Workers there is god progress. There are 26 medical workers in service. Another lot of eleven (11) medical social workers will be joining the service once the recruitment process is done.

RESOURCES

1. VEHICLES

REGISTRATION MODEL CAPACITY COMENTS 1. In good condition GK A 506 F Double cabin pick up 4 2. Grounded. Requires Kshs 500,000 GK Q 542 Pajero 8 for repair

2. MOTORBIKES None at present

3. LIST OF DONORS AND CONTRIBUTOR None currently

4. FINANCIAL ALLOCATIONS The approved funds allocated are grossly inadequate.

CONSTRAINTS IN MENTAL HEALTH

Shortage of:- 1. Health personnel adequately trained in mental health. 2. Lack of physical facilities such as psychiatric units in the hospitals. 3. Inadequate supplies of essential psychotropic drugs and equipment such as electroconvulsive therapy machines to scans and electroencephalogram. There is also lack of occupational therapy materials. 4. Inadequate transport · Vehicles · Motorcycles · Bicycles 5. Stigma on mental illness and mentally sick patients. 6. Lack of public awareness on mental health issues and the magnitude of mental health problems. 7. Lack of funds for Kenya Board of Mental Health to carry out its mandate according to the Mental Health Act, 1989 Cap 248.

WAY FORWARD IN MENTAL HEALTH

1. Completion of the mental health policy development. 2. Complete the National Mental Health Strategic Plan. 3. Revision of the mental health Act. 4. Implementation of decentralization and integration of mental health care within the general health care services with emphasis on promotion of good mental health within primary health care.

Annual Report 2003 - 2004 130 10. PUBLIC INSTITUTIONS

10.1 KNH inputs to the annual health performance report 2003 and 2004

Specialised services carried out in 2003 and 2004.

Radiotherapy and Nuclear Medicine

This department continues to realise only about 20% of service capacity due to machine breakdowns.

The superficial X-ray machine used for superficial X-ray therapy (SXT) broke down in the year 2000. It is the only one in the country and services are thus paralysed countrywide. A replacement has been sought estimated to cost about Kshs.15 million. Thyroid uptake studies are not being done as the machine broke down in the year 2002.

Simulation is currently being done through improvised use of C-arm X-ray. The Simulator itself broke down in the year 2000.

The International Atomic Energy Agency (IAEA) is currently undertaking a technical assistance project through which the hospital shall acquire a gamma camera and technicians trained to operate and to maintain it. The project is estimated to cost US$300,000.

Annual Report 2003 - 2004 131 Table 85: Radiotherapy Procedures - 2003

RADIOTHERAPY PROCEDURES - 2003 PROCEDURE JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL

Cobalt 60 per visit 1887 1768 1765 1792 2178 1584 2676 2028 2249 2146 1762 1355 23190 sxt per field 002000000000 2 strontium of 90 per application 000100000000 1 thyroid up-take 010000000000 1

Thyroid scan 848120001100 25

Thyrotoxicosis Treatment 000000000000 0

Caesium Brachytherapy 000221200000 7

Radioiodine Treatment (thyroid cancer) 000200000120 5

Simulation 7000000000012 19

Treatment planning 000000000090 9

TOTAL 1902 1773 1775 1798 2182 1585 2678 2028 2250 2148 1773 1367 23259

Annual Report 2003 - 2004 132 Table 86: Radiotherapy Procedures - 2004

RADIOTHERAPY PROCEDURES - 2004

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL

Cobalt 60 per visit 1388 1619 1717 1931 1294 1790 2539 1893 2462 2355 2411 1420 22819 sxt per field 0 0 0 0 546 225 0 0 0 0 0 0 771 strontium of 90 per application 0 0 0 0 0 121 0 0 0 0 0 0 121 thyroid up-take 0 0 0 0 0 0 0 0 0 0 0 0 0

Thyroid scan 0 0 0 0 0 0 4 0 0 0 1 2 7

Thyrotoxicosis Treatment 0 0 0 0 0 0 0 0 0 0 0 0 0

Caesium Brachytherapy 0 0 0 0 0 0 0 0 0 0 0 0 0

Radioiodine Treatment (thyroid cancer) 0 0 0 0 0 2 0 2 0 0 0 0 4

Simulation 11 103 58 87 93 243 152 102 153 108 118 25 1253

Treatment planning 0 0 65 0 0 0 0 0 0 0 0 0 65

TOTAL 1399 1722 1840 2018 1933 2381 2695 1997 2615 2463 2530 1447 25040

Annual Report 2003 - 2004 133 10.1.1 Renal Unit

VISION OF THE UNIT

To be a unit of excellence in provision of renal services in Kenya and the East African Region.

The unit runs both in-patient and out-patient services, that is, all renal patients are reviewed in this unit.

The unit has its own laboratory and renal pharmacy and provides all the three renal replacement therapies i.e. Haemodialysis, Peritoneal dialysis and Renal transplants.

The unit also co-ordinates training for basic and post basic students who rotate at the unit during their training.

Haemodialysis i. Patients

Since the year 2000, the number of patients seeking renal services has gone up. Patients started on haemodialysis, the number has steadily increased since the year 2000. Currently 120 patients are undergoing haemodialysis on an average of 25-30 patients daily. Started on continuous ambulatory peritoneal dialysis. This therapy is environment and hygiene depended and the numbers of patients on this therapy have gone down. There are 8 patients undergoing peritoneal dialysis.

Number of machines As noted above, over the years the number of patients who require this service has gone up thus requiring more machines. This has been a problem as a number of machines are broken down due to overwork and lack of service because the machines run 24 hours as they are few. Maximum of 36 sessions in a day are realisable but now it is 24 – 30 sessions realised. The unit also receives patients who are HIV positive and HCV negative who will require haemodialysis but due to lack of machines the service is not offered. These patients are offered peritoneal dialysis as an alternative.

Renal Biopsy

The optimal levels, about four patients per week are not reached because the service is expensive for the common man. Sometimes due to non-availability of biopsy needles the service is not offered in time.

Transplants

Twenty three patients (23) have been transplanted since the year 2000. The rate of renal transplant has gone down due to the rise in poverty level. There is a post transplant clinic run in the unit on Fridays. A total 80 patients come to this clinic on appointments.

Supplies and Equipment

In the year 2000 the unit received new dialysis machines Gambro AK 95 haemodialysis machines 19 in number. This replaced the old AK 10 machines which had worn out.

Presently the state of a number of the machines is good after repairs which were carried out early this year.

Supplies

In the year 2000 the hospital started a renal pharmacy to control and issue the items for renal dialysis. This has improved the services of the unit a great deal.

However, the supply of dialysis items has remained erratic since the items are expensive and the hospital is putting a lot of efforts to make them available for the patients.

Annual Report 2003 - 04 134 STAFF DEVELOPMENT

Nurses

Due to the increased demand of the renal services, the number of nurses in the unit was increased but the number is still deficient. In the year 2000 the hospital started a Renal Nursing course. Two classes have already qualified and a total of 26 nurses trained. Currently there is a class of 17 students running.

The Renal nursing course has improved the quality of nursing care in the unit. The unit has a nursing staff of 30 nurses, 17 of whom are renal trained while 13 are not renal trained.

Doctors

Since the year 2000 the unit has trained one doctor who has also left for private sector. One doctor has just been sent to South Africa for training.

Constraints

1. Although the cost of renal dialysis is already cost-shared in the hospital, dialysis still remains expensive for the common man. There are a number of renal patients in the medical wards and in the country as a whole who require a renal replacement therapy but cannot afford.

2. The unit is currently congested because it is the only public renal dialysis centre serving the whole country. The unit also serves our neighbouring countries, Uganda, Tanzania and Burundi.

3. There is a shortage of haemodialysis machines to cater for all patients in the country who need this service.

4. Lack of doctors to run the renal unit. The unit requires permanent resident doctor to have 24 hours medical cover.

Table 87: Renal Unit Procedures - 2003

RENAL UNIT PROCEDURES 2003

PROCEDURE JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL

HAMODIALYSIS 765 727 774 645 575 628 661 713 662 826 550 620 8146

BIOPSY 200000012803 16

TRANSPLANT 000000001000 1

TOTAL 767 727 774 645 575 628 661 714 665 834 550 623 8163

Annual Report 2003 - 04 135 Table 88: Renal Unit Procedures - 2004

RENAL UNIT PROCEDURES - 2004

PROCEDURE JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL

HAEMODIALYSIS 648 706 778 697 556 561 583 705 646 642 661 507 7690

BIOPSY 178220231440 34

TRANSPLANT 001000051000 7 PERITONIAL DIALYSIS 107 125 118 29 49 18 16 29 35 52 52 81 711

TOTAL 756 838 905 728 607 579 601 742 683 698 717 588 8442

Cardiology and EEG departments

Numbers of open heart operations carried out in the year 2003 were seventy five (75) cases. The target for the year 2003 was one hundred (100) cases but due to recurrent changes of consumables, only the above were done.

Number of open heart surgery carried out in the year 2004 to October 31st was forty nine (49) cases. The target for these years had been one hundred and fifty (150) cases but apart from shortages that bedevilled the unit, there were frequent breakdown of Cath lab equipment. The echocardiogram machine is overdue for replacement and unable to give good images. The ICU equipment has not been running very smoothly and the output has been revised to about eighty (80) patients.

In general it has been observed that whereas previously 40-50% of patients were requesting for waivers the hospital is now getting requests for waivers on almost 90% of the patients. This impacts negatively on the output because it is an expensive unit to run and if inflows are minimal the hospital will find it increasingly difficult to support the unit.

Table 89: Cardiac and EEG procedures 2000 - 2004

NO. OF PATIENTS PROCEDURE 2000 2001 2002 2003 2004 E.E.G. 1,713 490 1156 541 888 E.C.G. 2,665 2628 3101 3583 3760 E.S.T. 32 36 24 12 15 ECHO CARDIOGRAM 1,909 2230 2499 2618 2675 CARDIAC 117 134 113 220 148 CATHETERIZATION

Annual Report 2003 - 04 136 Table 90: Cardiac procedures 2003

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL ECHO 250 230 253 194 252 190 216 215 240 229 174 175 2618 ECG 336 304 308 291 334 331 304 336 359 244 181 255 3583 EST 4 6 0 0 0 0 0 0 0 1 0 1 12 CATHETERIZATION 8 18 23 11 17 18 18 37 16 15 14 25 220 TOTAL 598 558 584 496 603 539 538 588 615 489 369 456 6433

ELECTRO ENCEPHLOGRAM PROCEDURES 2003 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL NO. OF PATIENTS 0 0 0 111 79 62 60 84 83 62 0 0 541

Note: The EEG equipment was broken down in the months of January to March and November to December.

Table 91: Cardiac procedures 2004

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL

ECHO 196 203 242 218 221 222 264 209 265 236 216 183 2675

ECG 328 287 320 218 291 307 351 291 372 314 355 326 3760

EST 3 1 1 0 3 2 0 1 2 0 1 1 15

CATHETERIZATION 9 11 21 23 15 16 16 29 2 6 0 0 148

TOTAL 536 502 584 459 530 547 631 530 641 556 572 510 6598

ELECTROENCEPHALOGRAM PROCEDURES (EEG) - 2004

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL

NO. OF PATIENTS 96 62 88 67 76 82 76 72 71 76 68 54 888

2. (a) HIV/AIDS Vaccine Trials KNH has only provided the infrastructure and site for recruitment of trial subjects. Researchers are from the University of Nairobi. Resources are donor supported. Results so far are with the U.O.N. and can be obtained from them.

Randomised Control Trials carried out in 2002, 2003 and 2004

Please see 2 (a) above

Annual Report 2003 - 04 137 3. (a) TOP TEN OPD MORBIDITY FOR 2002, 2003 AND 2004 Table 92: Leading Causes of Out-Patient Attendance 2002 2003 2004 NO. DISEASE TITLE NO. OF CASES NO. OF CASES NO. OF CASES 1 Diseases Of Respiratory System 52245 54352 35351 2 Accidents (Incl Fractures & Burns) 28035 27591 27754 3 Ear Nose & Throat Disorders 25187 30972 30200 4 Eye Conditions 18556 16392 15029 5 Diseases Of Puerperium & Child Birth 17842 16336 13140 6 Rheumatism, Joint Pains 16529 17443 14669 7 Diseases Of Circulatory System 16363 16161 15394 8 Diseases Of The Skin (Incl. Ulcers) 14982 15004 9418 9 Pneumonia 14124 - - 10 Malaria 10026 - - 11 Diseases of Digestive system - 16863 17085 12 Diseases of Endocrine & Metabolic system - 13547 -

13 Diseases of Nervous system 10391 - 10391

All other diseases were 136,473 148299 113129

TOTAL CASES REPORTED 360,753 372,960 301,560

Figure 45: Major Outpatient Diseases Reported KNH 2002 - 2004

MAJOR OUTPATIENT DISEASES REPORTED KNH 2002-2004

160000

140000

120000

100000 2002 80000 2003 2004 60000

NUMBER OF CASES NUMBER 40000

20000

0

Malaria Pneumonia Eye Conditions

All other diseases were Rheumatism, Joint Pains Ear Nose & Throat Disorders Diseases of Digestive systemDiseases of Nervous system Diseases Of Respiratory System Diseases Of Circulatory System Accidents (Incl Fractures & Burns) Diseases Of The Skin (Incl. Ulcers) Diseases Of Puerperium & Child Birth

Diseases of Endocrine & Metabolic system CAUSES

Annual Report 2003 - 04 138 TOP TEN IN-PATIENT MORBIDITY FOR 2002, 2003 AND 2004

Table 93: Top Ten Leading Causes Of Hospitalization 2002

DISEASE TITLE ALIVE DEAD TOTAL CFR % Total Case

Pneumonia 6610 1639 8249 19.9% 9.0% Deliveries 5504 23 5527 0.4% 6.0% HIV/AIDS Disease 2819 1743 4562 38.2% 5.0% Malaria 4013 456 4469 10.2% 4.9% Diarrhoea And Gastroenteritis Of 2860 651 3511 18.5% 3.8% Presumed Infectious Origin Meningitis 1248 1174 2119 55.4% 2.3% Anaemias 1250 426 1676 25.4% 1.8% Bacterial Sepsis Of Newborn, 908 523 1431 36.5% 1.6% Unspecified Unspecified Abortion, Incomplete, No 1386 7 1393 0.5% 1.5% Complication T.B. Of Lung 958 351 1309 26.8% 1.4%

All other case were 49411 7720 57434 13.4% 62.6%

TOTAL CASES REPORTED 76,967 14,713 91,680 16.0% 100%

Table 94: Top Ten Leading Causes of Hospitalization 2003

NO. DISEASE TITLE ALIVE DEAD TOTAL CFR % Total cases 1 Pneumonia 7458 1573 9031 17.4% 8.7% 2 HIV/AIDS Disease 3822 1958 5780 33.9% 5.6% 3 Deliveries 5256 28 5284 0.5% 5.1% 4 Malaria 2861 354 3215 11.0% 3.1% 5 Meningitis 1395 1045 2440 42.8% 2.3% 6 Bacterial sepsis of newborn 1080 552 1632 33.8% 1.6% 7 Volume depletion 1173 428 1601 26.7% 1.5% 8 Anaemias 1052 399 1451 27.5% 1.4% 9 Diabetes Mellitus 1049 248 1297 19.1% 1.2%

Diarrhoea and gastroenteritis of 10 906 208 1114 18.7% 1.1% presumed infectious origin

All other diseases were 61886 9123 71009 12.8% 68.4%

TOTAL CASES REPORTED 87,938 15,916 103,854 15.3% 100.00%

Annual Report 2003 - 04 139 Table 95:Top Ten In-Patient Mortality For 2002 And 2003

NO. DISEASE TITLE 2002 2003

1 HIV/AIDS Disease 1743 1958 2 Pneumonia 1639 1573 3 Meningitis 1174 1045 Diarrhoea and Gastroenteritis of Presumed 4 651 - Infectious Origin

5 Bacterial Sepsis of Newborn, UNSP 523 552

6 Malaria 456 354 7 Anaemias 426 399 8 T.B. of Lung 351 - 9 Low Birth Weight 349 582 10 Volume Depletion 340 428 11 Respiratory distress of newborn 303 12 Diabetes Mellitus 248 All other disease were 7061 8474

TOTAL CASES REPORTED 14,713 15916

Note: The 2004 in-patient morbidity and mortality statistics have not been processed and shall be sent in the second quarter of 2005

10.1.2 Personnel

The following is the summary of staff establishment as at 31st December 2004. In December 2004, the Hospital was operating at 80% staff capacity – strength of 4944 against approved establishment of 6212. The staff gap of 20% means overstretching the available capacity. The obvious effect of this is low staff morale and high turnover.

With the current reduced funding from the Treasury, the Hospital cannot recruit personnel even for critical clinical areas. In particular, the nursing cadre is grossly understaffed. Given the ever-increasing patients number, the staff : patient ratio has been deteriorating over time.

To address these issues, the Hospital Management plans to restructure the Hospital and rationalise staff. The management also looks forward to a time when the Hospital will concentrate on handling referral cases only. This will greatly reduce patients’ number and thus improve the staff : patient ratio, and health care delivery to patients. Similarly, it is also hoped that in future the Hospital could consider charging full user fees. With improved revenue generation, the Hospital can employ optimal number of staff.

Annual Report 2003 - 04 140 Table 96: Summary of Approved Posts and Inposts (DECEMBER 2004)

CADRES TOTAL NUMBER DEFICIT EST. AVAILABLE (i) MEDICS:

Doctors - 311 272 39 Dentists - 50 29 21 Pharmacists - 18 10 8 Total - 379 311 68 (ii) PARAMEDICS

Nurses - 1948 1711 237 Clinical Officers - 134 65 69 Speech Therapist - 5 1 4 Lab. Technologists - 134 115 19 Lab. Technicians - 30 30 0 Pharmaceutical Technologists - 56 45 11 Radiographers - 43 21 22 Therapy Radiographers - 36 14 22 Radiographic Film Processors - 31 7 24 Nutrition officers/Assistants - 60 56 4 Dental Technologists - 39 14 25 Medical Physicists - 12 3 9 Radiation Safety Officer - 2 1 1 Cardiac/Neurophysiological Techno.- 12 4 8 Orthopaedic Technologists - 23 11 12 Orthopaedic Plaster Technician - 24 17 7 Medical Engineering Technologists/ Technicians - 29 27 2

Total - 2618 2142 476

(iii) PROFESSIONAL SUPPORT SERVICES: Physiotherapists - 86 65 21 Medical Social Workers - 46 28 18 Occupational Therapists - 53 35 18 Medical Records Officers - 47 35 12 Medical Records Assistants - 90 30 60 Public Health Officers - 10 9 1 Public Health Technicians - 25 11 14 Mausoleum Manager/ Mortuary Sup - 6 3 3 Profession in JG K6 (Position in Infection - 1 0 1 Control Unit)

Annual Report 2003 - 04 141 iv) ADMINISTRATIVE STAFF:

Director - 1 1 0 Deputy Director (CS) - 1 1 0 Deputy Director (AS) - 1 0 1 Administrative Officers - 43 32 11 Quality Assurance Officers - 11 0 11 Planning Officers - 4 3 1 Statistical Officers/Assistants - 3 0 3 Public Relations Officers - 3 2 1 Legal Officers - 2 2 0 Internal Auditors - 21 14 7 Audit Examiners - 6 0 6 System Analysts/Programmers - 4 4 0 Data Processing & Operations Officers - 2 0 2 Housekeepers/Cateress - 47 27 20 Superintending Engineers/Asst. Biomedical Eng. - 5 4 1 Inspectors/Superintendents - 28 22 6 Security Officers - 10 4 6 Telephone Supervisors - 7 2 5 Laundry /Tailoring Managers & Supervisors - 13 10 3 Personnel Officers/Assistants - 29 27 2 Accountants/Accounts Assistants - 45 39 6 Supplies Officers/Assistants - 38 30 8

Total 324 224 100

(v) OTHER CADRES

Draughtsman - 1 1 0 Carpenters - 12 9 3 Masons - 8 8 0 Painters - 9 7 2 Sign writers - 3 2 1 Plumbers - 12 8 4 Electricians - 20 16 Power Plant Mechanics - 2 3 -1 General Fitters - 12 8 4 RAC Mechanics - 6 2 4 Pipe Fitters - 9 2 7 Welders - 3 5 -2 Boiler Operators - 15 3 12 Medical Gases Operators - 8 4 4 Motor Vehicle Mechanics - 13 12 1 Motor Vehicle Electricians - 7 4 3 Motor Vehicle Panel

Annual Report 2003 - 04 142 Beater/ Sprayer - 3 2 1 Clerical Officers - 360 333 27 Store man - 57 49 8 Drain Sweepers - 3 3 0 Linen Markers - 2 2 0 Artisan Tailors - 40 36 4 Laundry Machine Operators - 42 32 10 Secretarial Staff - 124 98 26 Data Processing & Operations Assistants - 12 9 3 Superintendent Gardens - 2 2 0 Incinerator Operators - 4 2 2 Cooks - 50 41 9 Orthopaedic Appliance Markers - 8 3 5 Security Wardens - 55 45 10 Security Guards - 161 116 45 Drivers - 51 40 11 Office Machine Operators - 2 2 0 Toilet Cleaners - 29 2 27 Domestic Supervisors - 38 34 4 Porters - 36 21 15 Chaplains/Catechists - 9 7 2 Telephone Operators - 40 35 5 Receptionists - 2 0 2 Library Assistants - 2 1 1 Anaesthetic Assistants - 20 0 20

Total 1292 1009 283

(vi) AUXILLIARY STAFF

Sterile Services Assistants - 115 85 30 Theatre Services Assistants - 23 17 6 Pharmacy Assistants - 10 5 5 Earmold Assistants - 2 1 1 Family Health Field Educators - 3 1 2 Plaster Attendants - 23 12 11 Lab Assistants - 16 22 -6 Mortuary Assistants/Attendants- 32 22 10

Total 224 165 59

(vii) SUPPORT STAFF - 1011 877 134

GRAND TOTAL 6212 4944 1268

Annual Report 2003 - 04 143 Table 97: KENYATTA NATIONAL HOSPITAL administrative statistics 2000-2004

OP TOTAL YEAR ADMS DISCH DEATHS OBD ABD %OCC ALOS ATTEND. BEDS

2000 491302 1888 81930 73519 8177 764864 688686 111.1 9.4

2001 510686 1873 80775 74550 7849 722074 671256 107.6 9.1

2002 520181 1844 77629 69516 8203 737411 689610 106.9 9.5

2003 668147 1806 84879 75999 9119 745014 659190 113.0 8.8

2004 508888 1806 71428 63697 8028 703631 660996 106.5% 9.8

10.1.3 Annual Collections, Expenditures, Allocation 2002, 2003 And 2004

Included herein below are, Annual Collections, Expenditures and Budget allocations for the years indicated. 2001/2002 2002/2003 2003/2004 1ST HALF 2004/2005 Collections (Cost 807,143,993 596,463,453 52,385,271 367,048,844 sharing funds)

GOK Allocations 1,865,224,076 2,327,014,959 2,448,014,959 1,407,174,146

32,579,004 70,530,022 9,462,553 - Total Funds 2,704,947,073 2,994,008,434 3,409,862,793 1,774,222,990 available

Total 3,050,994,912 3,143,824,203 3,788,039,997 1,577,227,661 Expenditure

Surplus/(Deficit) -346,047,839 -149,815,769 -378,177,214 196,995,329

The total amount of funds available has increased from Kshs.2, 704,947,073 (2001/2002) to Kshs.3, 409, 862,783 (2003/2004). The increases have been due enhanced allowances payable to Medical Staff over the period.

The total expenditures have however been increasing more than the increase in revenue during the same period i.e. Kshs.3, 050,994,912 (2001/2002) to Kshs.3, 788,039,997 (2003/2004). The GOK has not funded both Operations and Maintenance Costs for the Hospital for a number of years. This has led to increasing levels of deficits over the years under review Kshs.346, 047,839 (2001/2002) to Kshs.378, 177,214 (2003/2004).

The Government should finance operations and Maintenance Costs in addition to Staff Costs to enable the Hospital break-even and/or generate surplus. This shall enhance quality provision of health care services.

Annual Report 2003 - 04 144 10.1.4 Resources Available a. Vehicles

Table 98: Vehicles as per Classifications

VEHICLE NO Saloon Cars 15 Pick-ups 8 Ambulances 3 Nissan Urvans 2 Minibuses 1 Hearse buses 2 Light trucks 2 Lorries 1 Motor cycles 3 Tractors and trailer 2 Total 39 b. Operational Constraints Report – Transport Section

The current number of drivers deployed in Transport Section is 41. However, the office operates on daily basis including night coverage for Laundry and Casualty as well as weekends and public holidays. Major constraints:

Most of the vehicles are worn out due to lengthy use and thus are regularly repaired.

Three (3) ambulances are inadequate to serve the entire Hospital. Two (2) of the ambulances are not fully equipped. They lack essential equipment like modern stretchers, oxygen for emergencies, etc. c. Donors

DONOR DONATIONS DESCRIPTION VALUE (KSHS.) 1. Washington University Extension of Patient Support 4 million Centre 2. National Bank of Kenya Extension of Patient Support 1.5 million Centre Waiting area 3. Family Health International Rehabilitation of Rahimtulla 8 million Comprehensive Care Centre 4. JICA/USAID V.C.T. Building, vehicles 6.1 million and equipment 5. JICA Laboratory Equipment (8 No.) 6. International Atomic Energy Agency Gamma Camera Project Assistance 23 million (IAEA)

WAY FORWARD

KNH through its strategic plan 2005-2010 identified major issues that influence effectiveness, efficiency and quality of services offered. Therefore the Hospital will focus on the strategic issues as follows:

· Legal Framework and Organizational Structure for the Hospital

The current and future challenges that face the Hospital require the current legal notice of the Hospital to be reviewed in order to establish the Hospital through an Act of Parliament. This will enable the Hospital to undertake its functions and responsibilities, within a legal framework that is appropriate, in the context of the health needs and requirements in Kenya and Internationally.

Annual Report 2003 - 04 145 Equipment and Physical Facilities

The Hospital has old and obsolete equipment and physical facilities that need to be rehabilitated, in order to continue providing specialized medical care, education and training and other services.

Human Resource Development and Management

The Hospital is a teaching and referral organization and it requires qualified and experienced health professionals and other technical staff in various disciplines in order to provide quality and effective services that are prescribed in its mandate. Therefore the Hospital requires terms and conditions of staff that will attract and retain the required personnel.

Financial Resource Management

Provision of adequate financing to cater for the core functions of the Hospital are essential taking into consideration the current Government Policy of financing Government institutions including the Hospital.

Procurement, Tendering and Management of Supplies

The Hospital is a big complex that requires huge supplies of materials required in providing quality health care, training and research and other services. Therefore effective and efficient policies and procedures are essential for procurement, tendering and management of supplies to ensure availability and cost effectiveness in the utilisation of the supplies.

Quality Assurance and Control Management

The public and stakeholders expect the Hospital to provide to enable the Hospital to attain optimal stakeholder satisfaction consistent with its vision and mission. To develop policy guidelines and management practices for effective management of the Hospital.

Hospital Image

KNH is well known both locally and internationally for its specialized health care services, training and research. It therefore must establish and maintain its positive reputation as a centre of excellence in providing quality health care services. To achieve this, the Hospital will need to develop mechanisms that will improve and maintain its public image in Kenya and within the region.

Training and Research in the Hospital

The Hospital will continue to provide training and research facilities and services to the university of Nairobi, College of Health sciences and other relevant training and research institutions for the improvement of health care services in Kenya. The Hospital will also continue to collaborate with regional and international institutions in the area of training and research for purposes of improving the delivery of health care services, training and research and other services that fall within the mandate of the Hospital.

Establishment of Inter - Institutional Linkages

The current trend of institutional development and sustainability is to develop a network with other like institutions for purposes of developing institutional capacities for their mandated functions. The current situation in Kenya and internationally requires KNH to establish and maintain linkages with other relevant institutions in order to achieve its mission and objectives.

Information and Communication Technology (ICT)

The Hospital requires establishing relevant ICT framework to enable it to cope with the dynamic environment in terms of Information Management and communication that is essential for effective planning, management and delivery of health care services in the Hospital.

Annual Report 2003 - 04 146 10.2 Moi Teaching and Referral Hospital

MOI Teaching and Referral hospital is the second largest referral hospital which serves the Western part of the republic of Kenya. The facility is strategic and situated on the great North Road. It has also a Medical school and well known for COBES V doctors.

Table 99: Top ten causes of outpatient morbidity mtrh 2002 – 2004 Disease 2002 % Total 2003 % Total 2004 Jan- % Total cases cases Oct. cases 1 Malaria 20,051 21.2% 18,359 20.2% 12,391 16.4% 2 Diseases of Respiratory 13,103 13.8% 10,348 11.4% 7,752 10.3% System 3 Accidents including 10,860 11.5% 10,661 11.7% 7,763 10.3% burns/fractures 4 Dental Disorders 7,452 7.9% 9,057 9.9% 7,689 10.2% 5 Disease of skin including 6,732 7.1% 4,610 5.1% 4,596 6.1% ulcers 6 Pneumonia 5,296 5.6% 4,133 4.5% 4,040 5.3% 7 Eye Infections 4,324 4.6% 7,716 8.5% 5,717 7.6% 8 Diarrhoeal Diseases 4,193 4.4% 3,127 3.4% 2,064 2.7% 9 Rheumatic fever including 3,117 3.3% 1,435 1.6% 0 0% joint pains 10 Ear Infections 2,689 2.8% 6,928 7.6% 4,049 5.3% 11 Urinary Tract Infections 0 0% 0 0% 3,004 4.0% All other diseases 16,777 17.7% 14,667 16.1% 16,491 21.8% Total cases were 94,594 100% 91,041 100.% 75,556 100.%

Table 100: Top ten causes of in-patient morbidity mtrh 2002 – 2004 Disease 2002 % Total 2003 % Total 2004 Jan- % Total cases cases June cases 1 Pregnancy Child birth & 6,591 27% 6,467 28% 3,233 27% pueperium 2 Malaria 2,686 11% 2,616 11% 918 8% 3 Diseases of Respiratory System 1,803 7% 1,874 8% 574 5% 4 Accidents /injuries 1,384 6% 1,046 5% 1,091 9% 5 HIV/AIDS 736 3% 824 4% 537 4% 6 Diarrhoeal Diseases 671 3% 714 3% 324 3%

7 Anaemia 512 2% 643 3% 286 2% 8 Tuberculosis 478 2% 412 2% 0 0% 9 Volume depletion ( dehydration) 309 1% 355 2% 183 2% 10 Diabetes 293 1% 234 1% 146 1% All other diseases 9,133 37% 7,643 33% 4,648 39% Total cases were 24,596 100% 22,828 100% 11,940 100%

Annual Report 2003 - 04 147 Table 101: Top ten causes of in-patient mortality moi teaching and referral hospital 2002 – 2004

Disease 2002 % Total 2003 % Total 2004 % Total cases cases Jan- Jun. cases 1 Pneumonia 221 9% 208 8% 86 6% 2 Malaria 182 8% 214 8% 44 3% 3 HIV/AIDS 141 6% 240 9% 155 12% 4 Tuberculosis 74 3% 36 1% 13 1% 5 Meningitis 70 3% 61 2% 28 2% 6 Gastro-Enteritis 68 3% 85 3% 25 2% 7 Dehydration 67 3% 46 2% 19 1% 8 Anaemia 65 3% 92 3% 30 2% 9 Accidents/Injuries 64 3% 48 2% 40 3% 10 Heart failure 58 2% 51 2% 39 3% All other diseases 1,318 57% 1,627 60% 851 64% Total cases were 2,328 100% 2,708 100% 1330 100%

10.2.1 Moi teaching referral hospital specialised services

Most of the specialised services needed for the National referral Hospital are not being offered due lack of equipment and technical personnel to man the services. However, the following key services had been offered to patients as follows;

Table 102: MTRH specialised services 2000 – 2004

Year 2000 2001 2002 2003 2004 Jan- Oct Laboratory 66,542 120,952 146,927 118,844 177,920 Radiology ( 15,547 16,458 22,543 10,385 21,557 X-Ray)

Table 103: Hospital administrative statistics 2002 – 2004

Year OPD Total Admis Disch Deaths OBD ABD % OCC ALOS ATT. Beds 2002 153,236 429 21,492 19,873 1,605 143,588 154,947 93 7 2003 167,733 443 21,857 20,110 1,775 166,652 161,695 103 8 2004 Jan- 140,000 459 17,700 15,997 1,357 126,590 139,995 90 7 Oct

Table 104: Annual allocations, collections and expenditures mtrh 2002 – 2004

YEAR INCOME (KSHS) ALLOCATION GRANTS EXPENDITURE (KSHS) (KSHS) 2002 221,857,231.00 352,332,539.00 525,158,995.00 2003 280,832,231.00 421,459,914.00 737,785,138.00 2004 330,787,129.92 468,072,075.40 733,676,517.27

Annual Report 2003 - 04 148 Figure 46: MTRH allocations and expenditures 2002 - 2004

900,000,000.00

800,000,000.00

700,000,000.00

600,000,000.00

500,000,000.00 2002 2003 KSHS 400,000,000.00 2004

300,000,000.00

200,000,000.00

100,000,000.00

0.00 INCOME (KSHS) ALLOCATION GRANTS TOTAL FUNDS EXPENDITURE (KSHS) (KSHS) AVAILABLE AMOUNT

VEHICLES The hospital currently has 12 vehicles. Two of these vehicles belong to the Regional Blood Transfusion Centre (RBTC) and two are grounded.

Table 105: Current Vehicles in MTRH

Registration number Make of the vehicle Status of vehicle KAN 402U ZUZUKI (Jimmy) Good and operational KAN 381U MITSUBISHI (Pick Up) Good and operational KAN 515U NISSAN (URVAN) Good and operational KAL 384 NISSAN (URVAN) Good and operational GK A831G NISSAN (URVAN) Good and operational KAN 514U TOYOTA (HILUX) Good and operational KAN 613U PEUGEOT Good and operational KAL 388U TERRANS Good and operational KAQ 886E NISSAN URVAN FOR RBTC Good and operational KAQ 521Q TOYOTA HILUX FOR RBTC Good and operational GK 412 LANDROVER Grounded GK 156 LANDROVER (Shortchasis) Grounded

Table 106: Current Personnel in MTRH

Cadre Number in post Deficit Director 1 0 Deputy directors 3 2 Consultants and medical officers 56 32 Pharmacists 3 9 Dental specialist/ dental officers 4 9 Radiographers 22 7

Annual Report 2003 - 04 149 Dental technologists /COHOs 16 14 Pharmaceutical Technologists 23 22 Biomedical Engineering Technologists 27 6 Occupational therapists 19 3 Physiotherapists 22 0 Orthopaedic Technologists 10 3 Health educational officers 0 6 Registered Clinical officers 76 0 Nursing officers 482 119 Plaster technicians 20 0 Nutritionist 31 13 Social workers 22 0 Health Records and Information officers 0 0 All others are 929 131 Total staff 1766 376

CONTRAINTS

· Inadequate budgetary support from the government. The hospital hardly gets 40% of its budgetary requirements resulting to:- o Pending bills; currently the hospital has bills amounting to 70 million Kenya shillings. o Admitting the patients to the wards without giving the optimal clinical care; o Referring patients to Nairobi particularly to Kenyatta National Hospital. o Inability to offer appropriate facilities for the training of the medical personnel

Way forward Being a referral hospital serving a large number of patients from the Western Region of the country, it is inevitable that the teaching hospital provide quality health care to patients. It is therefore critical that the following is addressed;- 1. specialized facilities ; A number of specialized services need be in place and these are; · Intensive Care Unit (ICU) · Renal Unit · Cardio-thoracic Unit · Burns Unit · Sterile preparation Unit · Isolation Unit · Piped Medical gases.

2. Location disadvantage: The rural setting of the hospital is not able to attract key specialists in Various clinical disciplines. Additionally, majority of the clients are rural poor who may not be able to pay hospital bills and therefore quite often waived. Thus the need for allocation of funds for the hospital to provide incentives to consultants and ease the burden of unpaid bills.

3. Strategic plan: The last strategic plan outlines what the hospital as a teaching hospital should entail. It is anticipated that the stakeholders will in the next coming period support the hospital to achieve her vision and mission.

10.3 Mathari Mental Hospital

Mathari Mental hospital was established In 1910 as an asylum and it has evolved over years to its current status of specialised services as a National Mental hospital. The hospital has a bed capacity of 700 beds with an average of 6,000 Outpatient attendances and 3400 patients admitted annually. The core functions of the hospital are to provide curative, preventive and promotive mental health services. The hospital also provides community outreach programme. The hospital has a staff establishment of 550 members of staff.

Annual Report 2003 - 04 150 Source of funds:

Mathari hospital gets its funds from the central government through the Ministry of Health. The 2003/2004 printed estimates show a total of Kshs 43, 941,170 for recurrent and Kshs 6,000,000/= for development (inclusive of staff salary, allowances and hospital running costs).

The cost-sharing supplements the above budgetary allocations. The hospital managed to collect a total of Kshs 17, 686, 923/= over the same period. The following are in-patient hospital morbidity statistics for 2003

Table 107: Causes of mental ill health/ Hospitalized in Mathari Mental hospital 2003.

Cause Male Female Total % total cases Psychological disorder 0 1 1 0% Mental disorder due to brain damage 7 8 15 1% Alcoholic psychosis 34 4 38 3% Drug induced psychosis 114 10 124 9% Mental disorders due to cannabis 1 0 1 0% Drug addiction 63 8 71 5% Schizophrenia 334 118 452 31% Acute psychosis 152 70 222 15% Schizo-affective disorder 49 38 87 6% Non – organic psychosis unspecified 67 46 113 8% Maniac Episode 47 42 89 6% Affective disorder Bipolar 2 1 3 0% Depressive Episodes 45 55 100 7% Mood disorder 57 43 100 7% Puerperal psychosis 0 4 4 0% All others were 28 10 38 3% TOTAL CASES WERE 1000 458 1458 100%

The 5 leading causes of mental ill health are:

· Schizophrenia · Psychosis · Drug induced psychosis · Non-organic psychosis · Depressive Episode

Constraints:

· The hospital infrastructure (buildings) was built nearly 100 years ago but due to lack of adequate funds to maintain they have dilapidated. The rate of breakages is also quite high due to the nature of patients in the institution. · Inadequate allocation of funds. The cost-sharing meant to supplement is also minimal. About 60% of the patients are not able to pay their hospital fees and acts as a home for mentally sick. The hospital also admits criminal mental patients who constitute two thirds of the total in-patients. They usually exempted and the hospitals do not receive any assistance from the ministry of Home Affairs to support them. · Patient’s linen: The rate of wear and tear of linen is very high due to the nature of patients. The hospital requires special consideration as linen is concerned.

Annual Report 2003 - 04 151 11. LABORATORY SERVICES

The National Public Health Laboratory Services (NPHLS) is the national referral laboratory for National quality control. Its services and other laboratories in the district serve as centres for confirmation of disease investigation and quality control. In most circumstances district and provincial laboratories are not well equipped and therefore carryout procedures as pertains to availability of reagents and modern equipment.

11.1 Bacteriological Analysis

· Most Laboratories did not carry out stool cultures. These may be attributed to lack of facilities, and capacity to carry out bacteriological analysis. · The few facilities submitting reports had done only a few cultures (less than 50 samples in a year). · Few Samples taken are also not submitted to the NPHLS for Quality Assurance Analysis. · No single report on the following investigations carried out: - o Salmonella Typhi o E. coli o Shigella o Klebsiella o Anthrax o Meningitis ( Neiseria type) o Cryptococcus o Streptopneumal o Heamophilus Influenza in the few districts that have been reporting including provincial hospitals. · Nyanza, Nairobi and Western provinces no single report from any facility submitted to the NPHL for the last three years.

Serological investigations · No single report on the following investigation or tests carried out in all hospitals i.e. o Biopsies referred o CD4, CD8 count o PCR Clinical Chemistry Analysis · Quite a number of facilities checked for blood sugar and urea.

Food bacteriology investigations · No facility reported any sample taken for both food and drinks for investigation for the last three years. · NPHLS – Quality Assurance Lab (43) in the year 2004 carried out some investigations i.e. o Total food samples taken – 1057 o Satisfactory for consumptions – 725 o Unsatisfactory for consumptions – 332 that is 31.4% Urinalysis investigations · From the total number of urine samples taken, 3-5% had tested positive with sugar in all the facilities reported. · 10 % of the samples taken for schist soma Haematobium were positive in Kwale, Tana River and Taita Taveta districts. The rest of the districts had less than 5%. · 20 – 40% of the Uri sticks indicated positive for pregnancy.

Various strains of Cholera organisms have been isolated sin various regions of the country from 2000 – 2004

Annual Report 2003 - 04 152 The organisms identified were Ogawa and Inaba

Figure 47: Organisms of Cholera by District

16 15

14

12

10

8 7 7 7 Number of of samples Number

6

4 4 3 3

2 1 1 1

0 Nyando Garissa Kwale Nairobi Machakos Makueni Kajiado Homa Bay Districts

Ogawa Inaba No Organisms isolated

11.2 Cholera organisms isolated by region

Figure 48: ORGANISMS ISOLATED BY PLACE OF OUTBREAK

16 15

14

12

Number of samples 10

8 7 7 7

6

4 4 3 3

2 1 1 1

0

Ahero Msambweni Mtito Andei Makindu Kitengela Fisheries Ifo Refugee camp Getrudes Hospital

Place of outbreak

Ogawa Inaba No Organisms isolated

Annual Report 2003 - 04 153 Table 108: Age Distribution of Cholera Cases By District

Mtito- Homa- Ahero Ifocamp Kwale Makindu Andei bay Kajiado Age 0-4years 0 1 1 2 0 0 0 Age 5-14years 0 2 0 0 0 0 0 Age 15-29years 3 2 2 4 0 0 0 Age 30-44years 0 1 2 0 0 0 0 Age 45yrs & above 0 0 0 1 0 0 0 Age Not specified 0 1 0 0 7 1 0

Figure 49: Age Distribution by Place of Cholera Outbreak

8

7 7

6

5

4 4

3 3

Number of samples 2 2 2 2 2 2

1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Ahero Ifocamp Kwale Makindu Mtito-Andei Homa-bay Kajiado PLACES OF OUTBREAK

Age 0-4years Age 5-14years Age 15-29years Age 30-44years Age 45yrs & above Age Not specified

Annual Report 2003 - 04 154 11.3 Drug Effectiveness Table 109: Drug effectiveness % % % % done Total Total tested samples Sensitive Resistant NotDone number ofnumber Sensitivity Drug

Ampicilin 0 0.0% 11 22.4% 38 77.6% 49 11 22.4%

Tetracyclin 13 26.5% 1 2.0% 35 71.4% 49 14 28.6%

Nitrofurantoin 2 4.1% 5 10.2% 42 85.7% 49 7 14.3%

Nalidixic acid 6 12.2% 1 2.0% 42 85.7% 49 7 14.3%

Streptomycin 1 2.0% 5 10.2% 43 87.8% 49 6 12.2% Sulphamethoxaz 1 2.0% 12 24.5% 36 73.5% 49 13 26.5% ole Cotrimoxazole 0 0.0% 7 14.3% 42 85.7% 49 7 14.3%

Erythromycin 4 8.2% 0 0.0% 45 91.8% 49 4 8.2%

Gentamycin 7 14.3% 0 0.0% 42 85.7% 49 7 14.3%

Ciprofloxacin 12 24.5% 0 0.0% 37 75.5% 49 12 24.5%

Oxfloxacin 3 6.1% 0 0.0% 46 93.9% 49 3 6.1%

Cefuroxime 2 4.1% 3 6.1% 44 89.8% 49 5 10.2%

augumentin 0 0.0% 2 4.1% 47 95.9% 49 2 4.1%

chloramphenical 1 2.0% 0 0.0% 48 98.0% 49 1 2.0%

Cefuroxime 3 6.1% 2 4.1% 44 89.8% 49 5 10.2%

Annual Report 2003 - 04 155 Figure 50: Percentage of effectiveness of drugs

60

50

40

30

Number of samples Number 20

10

0

Ampicilin Tetracyclin Oxfloxacin Gentamycin Cefuroxime augumentin Cefuroxime Nalidixic acid Streptomycin Erythromycin Ciprofloxacin Nitrofurantoin Cotrimoxazole chloramphenical Sulphamethoxazole Drugs

Sensitive Resistant Not Done

Table 110: Malarial Investigations % VE < 5YRS % +VES SPECIES NO +VES MONTHS XAM PROVINCE DISTRICT YEAR REPORTED TOTAL SLIDES E

EASTERN MACHAKOS 2002 2003 3275 329 10% 122 4% Falciparum 8 2004 MAKUENI 2002 801 459 57% 100 12% Not indicated 2 2003 2879 1447 50% 330 11% Falciparum 4 2004 8341 3708 44% 892 11% Falciparum 4 MARSABIT 2002 2003 2004 759 280 37% 0% Not indicated 2 MBEERE 2002 874 376 43% 152 17% Falciparum 2 2003 3094 1500 48% 431 14% Falciparum 3 2004 MERU CENTRAL 2002 2003 4183 2034 49% 0% Falciparum 2 2004 MERU NORTH 2002 2003 953 597 63% 114 12% Not indicated 5 2004 1679 746 44% 162 10% Falciparum 7 MERU SOUTH 2002 2003 986 485 49% 153 16% Not indicated 1 2004

Annual Report 2003 - 04 156 % VE < 5YRS % +VES SPECIES NO +VESNO MONTHS XAM PROVINCE DISTRICT YEAR REPORTED TOTAL SLIDES E MWINGI 2002 7581 3128 41% 0% Not indicated 11 2003 1729 681 39% 0% Not indicated 2 2004 4940 1723 35% 0% Not indicated 5 SUB -TOTAL 2002 9256 3963 43% 252 3% 2003 17099 7073 41% 1150 7% 2004 15719 6457 41% 1054 7% MOMBASA 2002 2003 2898 845 29% 0% Not indicated 1 2004 COAST TAITA TAVETA 2002 2962 1038 35% 0% Not indicated 6 2003 3498 793 23% 0% Not indicated 4 2004 2629 747 28% 0% Not indicated 2 TANA RIVER 2002 1090 584 54% 0% Not indicated 8 2003 2091 1347 64% 0% Not indicated 10 2004 4089 2619 64% 0% Not indicated 8 KWALE 2002 2003 16372 6194 38% 208 1% Falciparum 6 2004 23782 8824 37% 2911 12% Falciparum 8 SUB -TOTAL 2002 4052 1622 40% 0 0% 2003 24859 9179 37% 208 1% 2004 30500 12190 40% 2911 10% RIFT BARINGO 2002 VALLEY 2003 2004 7891 7096 90% 863 11% Falciparum 4 NANDI NORTH 2002 14714 9522 65% 0% Not indicated 6 2003 11438 6563 57% 0% Not indicated 4 2004 KAJIADO 2002 132 36 27% 0% Not indicated 1 2003 2004 NAKURU 2002 745 186 25% 30 4% Not indicated 1 2003 1517 711 47% 74 5% Not indicated 6 2004 KERICHO 2002 2003 13600 1638 12% 825 6% Falciparum 8 2004 KOIBATEK 2002 2003 3082 732 24% 124 4% Falciparum 8 2004 687 259 38% 94 14% Falciparum 2 TRANS NZOIA 2002 244 123 50% 0% Not indicated 1 2003 2004 TURKANA 2002 1005 291 29% 90 9% Falciparum 2 2003 6325 3047 48% 874 14% Falciparum 5 2004

Annual Report 2003 - 04 157 % VE < 5YRS % +VES SPECIES NO +VESNO MONTHS XAM PROVINCE DISTRICT YEAR REPORTED TOTAL SLIDES E SUB -TOTAL 2002 16840 10158 60% 120 1% 2003 35962 12691 35% 1897 5% 2004 8578 7355 86% 957 11% NYANDARUA 2002 CENTRAL 2003 10922 5287 48% 1168 11% Not indicated 7 2004 3110 1296 42% 293 9% Not indicated 3 NYERI 2002 7988 1288 16% 0% Not indicated 12 2003 2004 SUB -TOTAL 2002 7988 1288 16% 0 0% 2003 10922 5287 48% 1168 11% 2004 3110 1296 42% 293 9% GARISSA 2002 5507 3018 55% 0% Not indicated 12 N/EASTERN 2003 8053 5153 64% 0% Not indicated 12 2004 IJARA 2002 2003 2004 2088 1030 49% 380 18% Not indicated 12 SUB -TOTAL 2002 5507 3018 55% 0 0% 2003 8053 5153 64% 0 0% 2004 2088 1030 49% 380 18%

There is high significance between High parastemia in relation with severe Anaemia (Parastemia 57 – 90% HB < 5g% 16 – 38%). These were seen in Nandi North, Tana River, Turkana, Taita Taveta, Makueni and Mwingi districts.

11.4 Tuberculosis and haemogram levels by district 2002 – 2004

Table 111: TB and HB investigations S Full % VE < 5YRS % +VE NO +VES MONTHS HB <5g % Haemogram REPORTED PROVINCE DISTRICT YEAR % HB < 5g% TOTAL AFB EXAM

EASTERN MACHAKOS 2002 2003 1093 107 10% 0 0% 349 36 10% 8 2004 MAKUENI 2002 2003 1596 78 5% 0 0% 695 174 25% 4 2004 649 37 6% 3 0% 366 139 38% 3 MARSABIT 2002 2003 2004 117 8 7% 0 0% 270 31 11% 2

Annual Report 2003 - 04 158 S Full % VE < 5YRS % +VE NO +VESNO MONTHS HB <5g % Haemogram REPORTED PROVINCE DISTRICT YEAR % HB < 5g% TOTAL AFB TOTAL EXAM MBEERE 2002 46 0 0% 0 0% 45 8 18% 3 2003 221 9 4% 0 0% 242 5 2% 4 2004 MERU CENTRAL 2002 2003 506 57 11% 0 0% 584 39 7% 2 2004 MERU NORTH 2002 2003 171 29 17% 0 0% 120 7 6% 5 2004 371 61 16% 1 0% 249 20 8% 7 MERU SOUTH 2002 2003 108 0 0% 0 0% 104 55 53% 1 2004 MWINGI 2002 1781 278 16% 0 0% 1,453 216 15% 11 2003 175 23 13% 0 0% 464 43 9% 3 2004 1089 160 15% 0 0% 774 82 11% 6 SUB -TOTAL 2002 1827 278 15% 0 0% 1,498 224 15% 2003 3870 303 8% 0 0% 2,558 359 14% 2004 2226 266 12% 4 0% 1,659 272 16% COAST MOMBASA 2002 2003 756 144 19% 0 0% 2,433 412 17% 1 2004 TAITA TAVETA 2002 197 29 15% 0 0% 739 152 21% 6 2003 165 26 16% 0 0% 578 118 20% 4 2004 416 20 5% 0 0% 519 86 17% 2 TANA RIVER 2002 0 0 0 458 83 18% 8 2003 83 5 6% 0 0% 389 126 32% 10 2004 135 13 10% 0 0% 932 144 15% 3 KWALE 2002 2003 847 109 13% 0 0% 5,235 1,526 29% 6 2004 1320 169 13% 0 0% 8,532 1,336 16% 7 SUB -TOTAL 2002 197 29 15% 0 0% 1,197 235 20% 2003 1851 284 15% 0 0% 8,635 2,182 25% 2004 1871 202 11% 0 0% 9,983 1,566 16% RIFT VALLEY BARINGO 2002 2003 2004 495 24 5% 0 0% 2,323 167 7% 4 NANDI NORTH 2002 681 92 14% 0 0% 2,733 666 24% 6 2003 830 102 12% 0 0% 3,540 858 24% 5 2004 KAJIADO 2002 2003 2004 NAKURU 2002 2003 214 13 6% 0 0% 459 12 3% 3 2004 237 14 6% 0 0% 1,069 70 7% 3

Annual Report 2003 - 04 159 S Full % VE < 5YRS % +VE NO +VESNO MONTHS HB <5g % Haemogram REPORTED PROVINCE DISTRICT YEAR % HB < 5g% TOTAL AFB TOTAL EXAM KERICHO 2002 2003 2169 110 5% 8 0% 3,338 713 21% 8 2004 KOIBATEK 2002 2003 1632 168 10% 0 0% 237 39 16% 8 2004 408 42 10% 0 0% 72 12 17% 2 TRANS NZOIA 2002 18 2 11% 1 2003 2004 TURKANA 2002 732 0 0% 0 0% 433 9 2% 2 2003 809 45 6% 0 0% 1,948 452 23% 5 2004 SUB -TOTAL 2002 1413 92 7% 0 0% 3,184 677 21% 2003 5654 438 8% 8 0% 9,522 2,074 22% 2004 1140 80 7% 0 0% 3,464 249 7% CENTRAL NYANDARUA 2002 2003 1169 111 9% 0 0% 1,600 97 6% 7 2004 224 11 5% 0 0% 185 10 5% 3 NYERI 2002 1643 483 29% 0 0% 2,251 251 11% 12 2003 2004 SUB -TOTAL 2002 1643 483 29% 0 0% 2,251 251 11% 2003 1169 111 9% 0 0% 1,600 97 6% 2004 224 11 5% 0 0% 185 10 5% N/EASTERN GARISSA 2002 2003 8053 5153 64% 0 0% 3,334 - 0% 12 2004 SUB -TOTAL 2002 0 0 0 - - 2003 8053 5153 64% 0 0% 3,334 - 0% 2004 0 0 0 - -

Table 112: Immun0 haematology investigations 2002 - 2004 ED

PROVINCE DISTRICT YEAR BRUCELLA NO +VE % +VE HB SAG NO +VE HB SAG % +VE HIV HIV +VE % HIV + MONTHS REPORT

MACHAK EASTERN OS 2002

2003 32 9 28% 226 3 1% 435 85 20% 8 2004

Annual Report 2003 - 04 160 ED

PROVINCE DISTRICT YEAR BRUCELLA NO +VE % +VE HB SAG NO +VE HB SAG % +VE HIV +VE HIV % HIV + MONTHS REPORT MAKUEN I 2002

2003 607 16 3% 165 6 4% 729 178 24% 4

2004 919 30 3% 602 25 4% 1,039 193 19% 6 MARSAB IT 2002 2003

2004 0 0 38 1 3% 46 11 24% 2

MBEERE 2002 0 0 - - 13 1 8% 3

2003 445 199 45% - - 13 7 54% 4 2004 MERU CENTRA L 2002

2003 199 27 14% 132 8 6% 368 50 14% 2 2004 MERU NORTH 2002 17 2003 34 10 29% 6 1 % 47 11 23% 5 100 2004 93 44 47% 1 1 % 44 6 14% 7 MERU SOUTH 2002 20 2003 15 4 27% 20 4 % 205 46 22% 1 2004 10 MWINGI 2002 69 6 9% 29 3 % 781 227 29% 11 33 2003 0 0 3 1 % 73 33 45% 11 18 2004 173 68 39% 114 20 % 426 146 34% 11 SUB - 10 TOTAL 2002 69 6 9% 29 3 % 794 228 29%

2003 1332 265 20% 552 23 4% 1,870 410 22%

2004 1185 142 12% 755 47 6% 1,555 356 23% MOMBAS COAST A 2002 14 2003 2 0 0% 28 4 % 357 169 47% 1 2004 TAITA 2002 0 0 4% 31 16 52% 6

Annual Report 2003 - 04 161 ED

PROVINCE DISTRICT YEAR BRUCELLA NO +VE % +VE HB SAG NO +VE HB SAG % +VE HIV +VE HIV % HIV + MONTHS REPORT TAVETA 120 5

2003 1 0 0% 64 2 3% 39 12 31% 4

2004 0 0 0% 94 3 3% 128 17 13% 2 TANA RIVER 2002 0 0 0% - - 108 14 13% 8

2003 0 0 0% - - 95 5 5% 10

2004 0 0 0% 7 - 0% 123 20 16% 4 KWALE 2002

2003 3 1 33% 341 24 7% 729 148 20% 6

2004 4 0 0% 909 58 6% 1,423 360 25% 7 SUB - TOTAL 2002 0 0 120 5 4% 139 30 22%

2003 6 1 17% 433 30 7% 1,220 334 27%

2004 4 0 0% 1,010 61 6% 1,674 397 24% RIFT BARING VALLEY O 2002 2003 14 2004 337 52 15% 77 11 % 185 49 26% 4 NANDI NORTH 2002 535 231 43% 397 7 2% 539 10 2% 7

2003 107 31 29% 160 1 1% 149 1 1% 6 2004

KAJIADO 2002 49 20 41% - - 0% 23 4 17% 1 2003 2004

NAKURU 2002 39 9 23% - - 0% 18 3 17% 1

2003 114 17 15% - - 0% 73 9 12% 3

2004 73 13 18% - - 0% 314 65 21% 3 KERICHO 2002

2003 299 40 13% 619 10 2% 6,038 541 9% 7

2004 68 8 12% 149 - 0% 648 44 7% 1 KOIBATE K 2002

2003 67 7 10% 14 1 7% 299 64 21% 8

Annual Report 2003 - 04 162 ED

PROVINCE DISTRICT YEAR BRUCELLA NO +VE % +VE HB SAG NO +VE HB SAG % +VE HIV +VE HIV % HIV + MONTHS REPORT

2004 45 11 24% 2 - 0% 77 25 32% 2 TRANS NZOIA 2002 26 16 62% - - 0% - - 0% 1 2003 2004 TURKAN A 2002 73 6 8% 130 12 9% 326 33 10% 2

2003 193 21 11% 85 8 9% 281 31 11% 5 2004 SUB - TOTAL 2002 722 282 39% 527 19 4% 906 50 6%

2003 780 116 15% 878 20 2% 6,840 646 9%

2004 523 84 16% 228 11 5% 1,224 183 15% NYANDA CENTRAL RUA 2002 327 18 6% 90 2 2% 372 57 15% 11

2003 159 55 35% 25 1 4% 642 115 18% 3 12 2004 0 0 0% 69 8 % 18 - 0% 3 16 NYERI 2002 0 0 0% 38 6 % 834 194 23% 12 2003 2004 SUB - TOTAL 2002 327 18 6% 128 8 6% 1,206 251 21%

2003 159 55 35% 25 1 4% 642 115 18% 12 2004 0 0 69 8 % 18 - 0% N/EASTERN GARISSA 2002

2003 115 0 0% - - 0% - - 0% 12 SUB - TOTAL 2002 0 0

2003 115 0 0% - - 2004 0 0 NPHLS NQC LAB NAIROBI 2002 0 0 0% 6,360 153 2% 6,360 107 2% 12

2003 0 0 0% 9,441 377 4% 9,441 104 1% 12

2004 0 0 0% 7,851 188 2% 7,851 107 1% 12

Annual Report 2003 - 04 163 Table 113: Serological investigations 2002 - 2004 NO +VES % VES VDRL WIDAL TESTS WIDAL % +VES WIDAL% +VES MONTHS REPORTED MONTHS

PROVINCE DISTRICT YEAR NO +VESWIDAL FOR VDRL/ USR TESTSVDRL/USR

EASTERN MACHAKOS 2002 2003 356 12 3% 962 170 18% 8 2004 MAKUENI 2002 21 2 10% 70 10 14% 1 2003 712 75 11% 279 16% 4 2004 1508 232 15% 910 33% 4 MARSABIT 2002 2003 2004 185 1 1% 7 1 14% 2 MBEERE 2002 37 2 5% 324 179 55% 3 2003 184 12 7% 900 57% 4 2004 MERU CENTRAL 2002 2003 934 17 2% 328 25% 2 2004 MERU NORTH 2002 2003 94 23 24% 294 126 43% 4 2004 282 26 9% 837 413 49% 7 MERU SOUTH 2002 2003 117 2 2% 97 - 0% 1 2004 MWINGI 2002 966 48 5% 563 140 25% 12 2003 399 18 5% 385 112 29% 4 2004 806 24 3% 172 11% 6 SUB -TOTAL 2002 1024 52 5% 957 329 34% 2003 2796 159 6% 30% 2004 2781 283 10% 28% COAST MOMBASA 2002 2003 92 1 1% - - 0% 1 2004 TAITA TAVETA 2002 1356 24 2% 308 134 44% 6 2003 403 8 2% 154 67 44% 4 2004 206 8 4% 191 64 34% 2 TANA RIVER 2002 249 7 3% 263 113 43% 6 2003 52 0 0% 28 10 36% 10 2004 263 5 2% - - 0% 4 KWALE 2002 2003 2834 112 4% 469 23% 6 2004 4175 103 2% 393 21% 8

Annual Report 2003 - 04 164 NO +VESNO % VDRL VES WIDAL TESTS % +VES WIDAL MONTHS REPORTED MONTHS

PROVINCE DISTRICT YEAR NO +VES FOR WIDAL VDRL/ USRTESTS VDRL/ SUB -TOTAL 2002 1605 31 2% 571 247 43% 2003 3381 121 4% 546 25% 2004 4644 116 2% 457 22% RIFT VALLEY BARINGO 2002 2003 2004 1422 33 2% 377 22% 4 NANDI NORTH 2002 2170 48 2% 47% 10 2003 1811 33 2% 47% 8 2004 KAJIADO 2002 2003 2004 NAKURU 2002 89 2 2% 122 66 54% 2 2003 47 10 21% 325 86 26% 3 2004 921 22 2% 325 117 36% 3 KERICHO 2002 2003 2444 17 1% 204 7% 7 2004 361 13 4% 469 103 22% 1 KOIBATEK 2002 2003 819 21 3% 721 164 23% 8 2004 172 3 2% 169 73 43% 2 TRANS NZOIA 2002 2003 2004 TURKANA 2002 247 40 16% 110 21 19% 2 2003 1067 51 5% 811 227 28% 5 2004 SUB -TOTAL 2002 2506 90 4% 47% 2003 6188 132 2% 27% 2004 2876 71 2% 670 25% CENTRAL NYANDARUA 2002 2003 1130 42 4% 770 25% 8 2004 89 0 0% 220 38 17% 3 NYERI 2002 2009 38 2% 231 18% 12 2003 2004 SUB -TOTAL 2002 2009 38 2% 231 18% 2003 1130 42 4% 770 25% 2004 89 0 0% 220 38 17% N/EASTERN GARISSA 2002 2003 2004

Annual Report 2003 - 04 165 NO +VESNO % VDRL VES WIDAL TESTS % +VES WIDAL MONTHS REPORTED MONTHS

PROVINCE DISTRICT YEAR NO +VES FOR WIDAL VDRL/ USRTESTS VDRL/ SUB -TOTAL 2002 0 0 2003 0 0 2004 0 0

Table 114: Parasitology and haematological investigations 2002 - 2004

PROVINCE DISTRICT YEAR NO OF STOOL SPECIMENS EXAMINED GROUPING BLOOD MATCHES X TESTS COOMBS DONORS MONTHS REPORTED EASTERN MACHAKOS 2002

2003 1604 346 169 28 - 8 2004 MAKUENI 2002 110 30 19 - - 1

2003 1175 877 187 15 - 4

2004 4601 1031 282 - 93 5 MARSABIT 2002 2003 2004 99 175 35 - - 2 MBEERE 2002 211 18 0 - - 3

2003 1870 676 169 28 - 4 2004 MERU CENTRAL 2002 2003 903 581 203 - - 2 2004 MERU NORTH 2002 2003 364 68 14 - - 4 2004 769 134 0 - - 7 MERU SOUTH 2002 2003 317 134 40 - - 1 2004

MWINGI 2002 2986 2249 717 - 16 12 2003 680 218 55 - - 1 2004 2056 1795 521 - - 6

SUB -TOTAL 2002 3307 2297 736 - 16

Annual Report 2003 - 04 166 PROVINCE DISTRICT YEAR NO OF STOOL SPECIMENS EXAMINED GROUPING BLOOD MATCHES X TESTS COOMBS DONORS MONTHS REPORTED

2003 6913 2900 837 71 -

2004 7525 3135 838 - 93 COAST MOMBASA 2002 2003 240 543 283 - - 1 2004 TAITA TAVETA 2002 673 191 121 - 140 6

2003 522 361 78 - 65 4 2004 504 428 136 - - 2 TANA RIVER 2002 304 226 34 - - 8 2003 236 118 27 - - 10 2004 449 209 84 - - 4 KWALE 2002 2003 4533 2694 743 - - 6 2004 7033 3806 1319 - - 8

SUB -TOTAL 2002 977 417 155 - 140

2003 5531 3716 1131 - 65 2004 7986 4443 1539 - - RIFT VALLEY BARINGO 2002 2003

2004 1085 937 388 42 - 4

NANDI NORTH 2002 538 1181 579 - 549 8

2003 334 1103 545 340 150 6 2004 KAJIADO 2002 35 14 9 - - 1 2003 2004 NAKURU 2002 62 218 18 - - 2 2003 117 297 22 - - 2 2004 228 929 72 8 - 4 KERICHO 2002

2003 2172 2232 972 25 - 7 2004 386 272 137 3 - 1 KOIBATEK 2002

2003 215 292 190 190 - 8

2004 48 87 65 77 - 2

Annual Report 2003 - 04 167 PROVINCE DISTRICT YEAR NO OF STOOL SPECIMENS EXAMINED GROUPING BLOOD MATCHES X TESTS COOMBS DONORS MONTHS REPORTED TRANS NZOIA 2002 7 2003 2004 TURKANA 2002 102 55 27 - - 2

2003 716 939 400 286 - 5 2004

SUB -TOTAL 2002 744 1468 633 - 549

2003 3554 4863 2129 841 150

2004 1747 2225 662 130 - CENTRAL NYANDARUA 2002

2003 2744 955 213 - 15 7

2004 407 93 42 - 86 2

NYERI 2002 2741 1502 808 - 521 12 2003 2004

SUB -TOTAL 2002 2741 1502 - 521

2003 2744 955 - 15

2004 407 93 - 86 N/EASTERN GARISSA 2002 2003 2449 1797 1013 - - 12 2004 SUB -TOTAL 2002 0 0 - - 2003 2449 1797 - - 2004 0 0 - - NAIROBI NAIROBI 2002

2003 1852 1050 - 1,070 2004 SUB -TOTAL 2002 0 00 - -

2003 0 1852 1050 - 1,070 2004 0 00 - -

Annual Report 2003 - 04 168 Way forward

· Improve by strengthening the data capture and reporting system. · Equip main hospitals with modern laboratory equipment. · Train all Lab personnel on Health Information. · Report all investigations carried out from facility through national levels. · Improve on data capture tools and review them.

Annual Report 2003 - 04 169 12. National Trends of Outpatient Morbidity The National causes of morbidity trends remains constantly with Malaria and Respiratory Infections taking position one and two respectively in the past 4 decades. Diarrhoeal diseases and intestinal worms, Accidents, Pneumonia and Rheumatisms has been exchanging positions in various provinces/regions but the two top most (Malaria and Respiratory diseases) has remained and accounting for over 55% of the total causes of morbidity.

In the year 2004, quite a large number of busy facilities reported and this can been seen from the reported cases. There is need for districts and provinces to follow-up private clinics and hospitals that are not submitting their reports. It’s hoped that during the year 2005 at least over 75% of the facilities will be able to report including the over 2000 private clinics. Nairobi and Coast provinces had the least number of reporting facilities and this was 4% and 11% response rate respectively.

Figure 51: National Top Ten Causes of Morbidity 2004

All other diseases 15% Eye infections 2% Urinary tract infection 2% Rheumatism, Joint pains etc Malaria 2% Malaria Dis.of the respiratory system Accidents (incl. Fractures, 32% Dis.of the skin (incl. Ulcers) burns etc) 3% Diarrheal diseases Intestinal worms Pneumonia 3% Pneumonia Accidents (incl. Fractures, burns etc) Intestinal worms 5% Rheumatism, Joint pains etc Urinary tract infection Diarrheal diseases 5% Eye infections All other diseases Dis.of the skin (incl. Ulcers) 7% Dis.of the respiratory system 24%

Annual Report 2003 - 04 170 Figure 52: Top Ten Causes of Outpatient Morbidity 2004 2000000

1800000

Malaria 1600000 Dis.of the respiratory system

1400000 Dis.of the skin (incl. Ulcers)

Diarrheal diseases 1200000 Intestinal worms

Pneumonia 1000000

NO OF CASES Accidents (incl. Fractures, burns etc)

800000 Rheumatism, Joint pains etc

Urinary tract infection 600000 Eye infections

400000 All other diseases

200000

0 Rift Valley Central Nyanza Eastern N/Eastern Nairobi Coast Western PROVINCE

Figure 53: Top Ten Causes of Outpatient Morbidity by Province 2003

All other cases were Western Eye Infection Rheumatism,Joint pains etc Uraniry Tract Infections Coast Pneumonia Accidents (incl.fructures,burns etc) Nairobi Intestinal Worms Diarrhoel Diseases Dis. Of the Skin (Incl. Ulcers N/Eastern Dis. Of the Respiratory System Malaria PROVINCE Eastern

Nyanza

Central

Rift Valley

0 200000 400000 600000 800000 1000000 1200000 1400000 1600000 CASES

Annual Report 2003 - 04 171 Table 115: Top Ten Causes of Morbidity 2004 by Province Rift % CAUSE Valley Central Nyanza Eastern N/Eastern Nairobi Coast Western National total Total Malaria 1692309 1090195 1378259 1861231 25680 84703 409106 1004056 7545539 33% Dis.of the respiratory system 1512398 1647883 481769 1190281 17798 115679 253984 375610 5595402 25% Dis.of the skin (incl. Ulcers) 337330 380737 186289 322919 2872 31581 83866 146763 1492357 7% Diarrhoeal diseases 264121 197533 170108 193626 5755 31683 57971 117853 1038650 5% Intestinal worms 147694 353471 88613 337071 3082 13861 29384 55872 1029048 5% Pneumonia 163085 93877 84472 138292 4196 8127 24977 82937 599963 3% Accidents (incl. Fractures, burns etc) 161973 157703 68353 115781 759 9601 19881 62008 596059 3% Rheumatism, Joint pains etc 87452 98288 47762 137256 1190 10980 12514 22172 417614 2% Urinary tract infection 81807 77902 54608 91054 3497 13152 24983 43077 390080 2% Eye infections 97559 82996 42924 81597 1150 9444 16631 22974 355275 2% All other diseases 892093 969887 527033 615302 12284 93326 165255 296191 3471311 15% Total cases were 5437821 5150472 3130190 5202041 78263 422137 1098552 2229513 22748989 100%

Table 116: Top Ten Causes of Outpatient Morbidity 2003 by Province

DISEASE Rift Valley Central Nyanza Eastern N/Eastern Nairobi Coast Western National total % total Malaria 1359609 666270 1176850 1058126 17949 64309 234885 760010 5338008 34% Dis. Of the Respiratory System 891579 1040508 423590 623477 9935 108265 137036 255199 3489589 23% Dis. Of the Skin (Incl. Ulcers 250344 237924 158472 189444 1868 26725 40813 90637 996227 6% Diarrhoeal Diseases 183560 122981 135328 114750 3337 23007 30106 86944 700013 5% Intestinal Worms 90280 213236 74162 176815 1460 8115 20256 38361 622685 4% Accidents (incl.fructures,burns etc) 112330 117499 56493 66500 772 24971 12716 48230 439511 3% Pneumonia 93997 72931 59735 83355 5373 14329 15129 66272 411121 3% Urinary Tract Infections 53931 55207 48342 59632 2439 13296 15104 32096 280047 2% Rheumatism, Joint pains etc 46595 66971 41069 58334 563 19629 6904 18432 258497 2% Eye Infection 65087 56615 31236 57767 1098 18831 8988 15374 254996 2% All other cases were 619447 725657 411774 426314 9498 177611 115129 214284 2699714 17%

Total cases were 3766759 3375799 2617051 2914514 54292 499088 637066 1625839 15490408 100%

Annual Report 2003 - 04 172 Annual Report 2003 - 04 173 Table 117: Out-patient morbidity provincial summary year 2004 Rift National PROVINCE Valley Central Nyanza Eastern N/Eastern Nairobi Coast Western total Number of reports expected 14,805 11,256 7,128 10,776 1,536 4,908 7,152 4,099 61,660 Number of reports received 9,792 6,019 4,652 6,700 195 193 808 2,677 31,036 % reporting completeness 66% 53% 65% 62% 13% 4% 11% 65% 50%

Diarrheal diseases 264,121 197,533 170,108 193,626 5,755 31,683 57,971 117,853 1,038,650

Tuberculosis 7,591 4,335 19,502 14,084 110 4,332 1,343 3,683 54,980

Leprosy 65 1 69 304 6 2 39 131 617

Whooping cough 305 125 1,586 112 89 69 18 390 2,694

Meningitis 223 118 461 182 6 18 21 484 1,513

Tetanus 225 212 48 70 35 4 23 57 674 Poliomyelitis (AFP cases) 179 2 66 46 1 4 - 12 310

Chicken pox 32,931 40,370 12,562 14,139 76 3,555 4,848 6,280 114,761

Measles (suspected) 1,497 1,057 654 897 21 218 244 401 4,989 Infectious hepatitis (jaundice) 1,019 587 1,000 699 28 58 683 375 4,449

Mumps 26,014 23,369 7,723 6,432 185 1,151 1,989 4,509 71,372

Malaria 1,692,309 1,090,195 1,378,259 1,861,231 25,680 84,703 409,106 1,004,056 7,545,539

Gonorrhoea 19,172 8,907 33,400 11,349 292 2,665 3,257 7,554 86,596 Urinary tract infection 81,807 77,902 54,608 91,054 3,497 13,152 24,983 43,077 390,080 Bilharzia (schistosomiasis) 3,743 4,008 6,736 5,196 790 499 6,568 562 28,102

Intestinal worms 147,694 353,471 88,613 337,071 3,082 13,861 29,384 55,872 1,029,048

Malnutrition 7,491 3,201 8,637 5,414 768 1,232 1,427 5,917 34,087

Anaemia 13,798 9,152 23,681 17,381 2,144 1,727 19,301 23,327 110,511

Eye infections 97,559 82,996 42,924 81,597 1,150 9,444 16,631 22,974 355,275

Cataract 5,249 1,984 1,803 3,305 139 239 260 521 13,500

Ear infections 60,905 54,332 32,494 53,634 1,391 5,991 12,104 18,617 239,468 Dis.of circulatory systems 28,580 56,655 17,547 35,230 278 4,238 5,987 9,582 158,097 Dis.of the respiratory system 1,512,398 1,647,883 481,769 1,190,281 17,798 115,679 253,984 375,610 5,595,402

Pneumonia 163,085 93,877 84,472 138,292 4,196 8,127 24,977 82,937 599,963

Annual Report 2003 - 04 174 Rift National PROVINCE Valley Central Nyanza Eastern N/Eastern Nairobi Coast Western total

Abortion 10,958 7,318 9,231 4,577 136 321 1,282 4,885 38,708 Dis.of puerperium and child birth 6,817 5,091 3,218 5,372 185 632 2,139 3,219 26,673

Neoplasms 1,172 1,715 997 872 33 143 195 745 5,872 Dis.of blood and blood forming organs 3,881 5,074 1,920 2,924 59 874 1,129 3,184 19,045

Mental disorders 8,357 17,659 4,157 12,696 170 372 2,410 3,243 49,064

Dental disorders 63,411 64,873 35,273 62,046 599 3,916 9,184 16,369 255,671 Dis.of the skin (incl. Ulcers) 337,330 380,737 186,289 322,919 2,872 31,581 83,866 146,763 1,492,357 Rheumatism, Joint pains etc 87,452 98,288 47,762 137,256 1,190 10,980 12,514 22,172 417,614

Congenital anomalies 2,925 1,828 1,307 1,517 10 285 406 582 8,860 Pyrexia of unknown origin (POU) 9,757 9,910 13,509 6,223 95 7,224 2,574 4,776 54,068

Poisoning 6,413 3,979 4,433 3,113 109 291 1,618 1,968 21,924 Accidents (incl. Fractures, burns etc) 161,973 157,703 68,353 115,781 759 9,601 19,881 62,008 596,059

98 - 207 9,964 - 2,703 2,272 2,855 18,099

2,671 - 21 17,159 - 249 504 350 20,954

355 - 100 4,545 - 5 1,702 1,729 8,436

All other diseases 566,291 644,025 284,691 433,451 4,529 50,309 81,728 169,884 2,234,908 TOTAL NEW CASES 5,437,821 5,150,472 3,130,190 5,202,041 78,263 422,137 1,098,552 2,229,513 22,748,989 RE-ATTENDANCES (RE-VISITS) 1,240,012 1,335,375 738,345 1,071,995 6,285 141,370 300,746 416,903 5,251,031

REFERRALS 215,037 39,053 45,795 59,505 491 8,641 8,245 28,023 404,790 NO.OF FIRST ATTENDANCES 2,514,589 2,316,742 1,065,487 2,680,027 7,181 110,144 483,627 939,882 10,117,679

Table 118: Out Patient morbidity district summary year 2003 (Central Province) PROVINCE Central prov. DISEASE Murang'a Nyeri Kirinyaga Maragua Thika Kiambu Nyandarua Total Number of reports expected 1260 3336 1764 1320 1020 912 1452 11064 Number of reports received 638 1112 481 384 565 780 591 4551 % reporting completeness 51% 33% 27% 29% 55% 86% 41% 41% Diarrhoel Diseases 10851 30050 16045 12151 17167 22709 14008 122981 Tuberculosis 51 614 616 408 695 302 342 3028 Leprosy 0 0 0 114 0 16 0 130 Whooping Cough 280 4 2 11 10 3 16 326 Meningitis 26 27 5 5 13 30 36 142 Tetanus 0 4 0 8 10 64 6 92

Annual Report 2003 - 04 175 PROVINCE Central prov. DISEASE Murang'a Nyeri Kirinyaga Maragua Thika Kiambu Nyandarua Total Poliomyelitis 0 0 0 0 1 58 0 59 Chicken Pox 4688 5492 2288 2652 2536 5608 2252 25516 Measles 27 303 47 175 83 174 31 840 Infectious Hepatitis(Jaundice) 27 131 38 186 48 148 96 674 Mumps 2714 3770 2361 1987 1508 4089 2517 18946 Malaria 92366 127659 148021 67699 97720 81767 51038 666270 Gonorrhoea 867 1732 325 2052 854 3482 1014 10326 Urinary Tract Infections 6156 14333 6341 4485 7420 11255 5217 55207 Bilharzia(Schistosomiasis 70 85 1399 546 525 1051 122 3798 Intestinal Worms 28830 58920 30322 28249 23660 29152 14103 213236 Malnutrition 442 363 157 553 722 934 118 3289 Anaemia 1336 1102 330 449 1941 1196 334 6688 Eye Infection 10963 13642 8619 4624 5385 7788 5594 56615 Cataract 246 136 152 167 114 984 118 1917 Ear Infections 7335 11789 4076 3208 3813 5282 3146 38649 Dis. Of the Circulatory System 2304 13224 2052 1894 2229 14220 3765 39688 Dis. Of the Respiratory System 140674 308938 131169 81340 120957 165862 91568 1040508 Pneumonia 6814 21938 6189 5740 9709 11846 10695 72931 Abortion 675 1069 448 325 514 513 825 4369 Dis. of puerperium and Child birth 154 706 220 222 353 860 487 3002 Neoplasms 15 562 64 113 53 185 550 1542 Dis. of blood forming Organs 88 577 395 154 100 340 1094 2748 Mental Disorders 1997 6397 1248 1230 436 697 1491 13496 Dental Disorders 8110 10026 12570 2098 1852 27618 8628 70902 Dis. Of the Skin (Incl. Ulcers 30040 80250 32230 23595 26511 22050 23248 237924 Rheumatism, Joint pains etc 9808 24400 8423 5517 4716 6729 7378 66971 Congenital Anomalies 139 234 76 108 129 3838 308 4832 Pyrexia of unknown Origin (PUO) 310 1809 741 472 950 8584 1718 14584 Poisoning 264 279 87 139 178 8684 400 10031 Accidents (incl.fructures,burns etc) 15112 27928 15237 8767 10623 27378 12454 117499 Typhoid Fever 275 0 3101 0 0 0 4990 8366 Brucellosis 16 0 49 0 0 0 1791 1856 ISS 1 0 0 0 0 0 116 117 All other Diseases 37988 132997 56953 39533 46994 65671 55568 435704 Total New Cases 422059 901490 492396 300976 390529 541167 327182 3375799 RE-ATTENDANCES (RE- VISITS) 104254 204992 121518 83578 48401 0 73466 636209 REFERRALS 5609 8614 2878 1811 2042 0 2202 23156 NO. OF FIRST ATTENDANCES 239776 492941 260200 215725 32151 0 193637 1434430

Annual Report 2003 - 04 176 Table 119: Out Patient morbidity district summary year 2004 (Central Province) iambu

DISEASE Muranga Nyeri Kirinyaga Maragua Thika K Nyandarua prov. Total Number of reports expected 1260 3336 1764 1320 1212 912 1452 11256 Number of reports received 631 1383 849 524 965 780 887 6019 % reporting completeness 50% 41% 48% 40% 80% 86% 61% 53% Diarrhoeal diseases 15397 41642 39966 15319 35500 22319 27390 197533 Tuberculosis 60 842 856 396 1428 197 556 4335 Leprosy 0 0 0 0 0 1 0 1 Whooping cough 1 4 113 1 2 2 2 125 Meningitis 7 13 1 2 21 62 12 118 Tetanus 0 2 2 5 4 199 0 212 Poliomyelitis 0 0 0 0 0 2 0 2 Chicken pox 4697 6012 6396 3327 6502 8031 5405 40370 Measles 35 412 192 40 102 193 83 1057 Infectious hepatitis (jaundice) 8 164 43 16 103 120 133 587 Mumps 2789 5260 3752 2322 2634 2876 3736 23369 10198 Malaria 114884 185333 272570 117207 193218 4 104999 1090195 Gonorrhoea 905 2008 818 1523 905 1282 1466 8907 Urinary tract infection 7078 18125 12496 5622 14454 9470 10657 77902 Bilharzia (schistosomiasis) 3 41 1421 637 480 1227 199 4008 Intestinal worms 38752 101177 56511 43352 56759 28775 28145 353471 Malnutrition 472 453 161 392 1178 307 238 3201 Anaemia 861 1454 510 632 4032 1160 503 9152 Eye infections 12316 18169 15312 6839 11530 8796 10034 82996 Cataract 114 188 297 116 136 1006 127 1984 Ear infections 6229 16970 6362 3990 6564 6256 7961 54332 Dis.of circulatory systems 1972 24306 3798 3701 2627 14156 6095 56655 17299 Dis.of the respiratory system 182233 451744 241214 155272 250254 3 194173 1647883 Pneumonia 5787 22341 14397 5963 18410 12247 14732 93877 Abortion 760 2008 420 264 1115 1570 1181 7318 Dis.of puerperium and child birth 122 899 490 270 803 1186 1321 5091 Neoplasms 41 977 37 85 176 126 273 1715 Dis.of blood and blood forming organs 159 1686 835 168 500 254 1472 5074 Mental disorders 1498 8631 1358 1864 779 771 2758 17659 Dental disorders 9687 11301 16911 3244 2615 7166 13949 64873 Dis.of the skin (incl. Ulcers) 40749 109757 62229 37828 60882 35580 33712 380737 Rheumatism, Joint pains etc 9877 36456 13501 8444 11916 6925 11169 98288 Congenital anomalies 39 533 107 110 188 435 416 1828 Pyrexia of unknown origin (POU) 1587 1807 1368 843 1331 1918 1056 9910 Poisoning 358 494 125 180 278 236 2308 3979 Accidents (incl. Fractures, burns etc) 19879 36168 22662 15532 22244 16982 24236 157703 All other diseases 43131 201340 70105 61623 93736 74755 99335 644025 TOTAL NEW CASES 522487 1308717 867336 497129 803406 54156 609832 5150472

Annual Report 2003 - 04 177 iambu

DISEASE Muranga Nyeri Kirinyaga Maragua Thika K Nyandarua Totalprov. 5 RE-Attended (revisits 123797 315096 245834 307127 176411 0 167110 1335375 REFERRALS 4089 12610 4732 3554 4586 0 9482 39053 NO.OF FIRST ATTENDANCES 317550 745125 559829 291755 16698 0 385785 2316742

Table 120: Out Patient morbidity district summary year 2003 (Western Province) DISEASE Busia Lugari Mt. Elgon Vihiga Kakamega Butere Bungoma Teso TOTAL Number of reports expected 456 492 143 942 1220 831 550 168 4802 Number of reports received 413 228 127 348 649 405 386 140 2696 % reporting completeness 91% 46% 89% 37% 53% 49% 70% 83% 56% Diarrhoel Diseases 21472 4122 3064 7246 13478 13894 16014 7654 86944 Tuberculosis 667 46 32 390 390 1620 375 142 3662 Leprosy 1 0 1 0 3 26 1 1 33 Whooping Cough 5 3 4 0 19 86 12 0 129 Meningitis 8 1 5 15 10 49 35 1 124 Tetanus 3 2 1 0 3 11 12 0 32 Poliomyelitis 0 0 1 0 1 1 0 0 3 Chicken Pox 280 305 255 264 515 620 545 123 2907 Measles 116 21 47 9 29 140 94 12 468 Infectious Hepatitis(Jaundice) 93 9 6 23 99 32 53 32 347 Mumps 321 32 43 61 270 448 85 29 1289 Malaria 125980 63541 35785 95733 147068 111550 133020 47333 760010 Gonorrhoea 1413 323 163 1235 1630 1975 0 193 6932 Urinary Tract Infections 4141 1741 882 2897 5961 5627 9694 1153 32096 Bilharzia(Schistosomiasis 328 0 6 8 80 78 1 25 526 Intestinal Worms 9571 1897 2531 6047 6765 4928 3966 2656 38361 Malnutrition 948 114 109 324 810 838 685 619 4447 Anaemia 3327 489 648 1890 3694 3107 4471 1128 18754 Eye Infection 3083 805 618 1476 2605 2969 3106 712 15374 Cataract 93 3 13 7 79 20 48 222 485 Ear Infections 2466 720 419 1528 2654 1854 2490 847 12978 Dis. Of the Circulatory System 505 133 72 1014 1422 285 589 128 4148 Dis. Of the Respiratory System 52971 23777 10791 27600 42828 44870 36888 15474 255199 Pneumonia 3577 1381 3037 18492 13338 3716 21673 1058 66272 Abortion 536 267 121 297 1448 673 835 200 4377 Dis of puerperium and Child birth 332 113 123 142 587 370 625 62 2354 Neoplasms 98 5 3 23 316 36 148 14 643 Dis of blood forming Organs 190 39 22 49 223 112 213 120 968 Mental Disorders 360 98 32 680 308 591 415 439 2923 Dental Disorders 1869 310 300 1383 3183 2037 3317 1362 13761 Dis. Of the Skin (Incl. Ulcers 19965 6089 3175 7460 15084 18306 15183 5375 90637 Rheumatism, Joint pains etc 1663 824 511 1059 2899 8629 2249 598 18432 Congenital Anomalies 51 7 18 57 311 56 75 23 598 Pyrexia of unknown Origin (PUO) 188 196 15 110 1013 1431 727 86 3766 Poisoning 180 51 52 63 439 212 204 124 1325 Accidents (incl.fructures,burns etc) 4932 2572 2800 5497 10125 8033 12737 1534 48230

Annual Report 2003 - 04 178 DISEASE Busia Lugari Mt. Elgon Vihiga Kakamega Butere Bungoma Teso TOTAL 0 0 0 0 0 0 0 132 132 0 0 0 0 0 0 0 9 9 0 0 0 0 0 0 0 0 0 All other Diseases 13363 7857 6320 21197 25890 21170 24439 5928 126164 Total New Cases 275096 117893 72025 204276 305577 260400 295024 95548 1625839 Re-attendances (Revisits) 80959 29745 7262 23502 84111 33455 66627 33828 359489 Referrals 2342 2636 336 1785 5676 7058 2415 821 23069 NO. of first Attendances 123260 66157 45370 58055 189083 47521 150382 55241 735069

Table 121: Out Patient morbidity district summary year 2004 (Western Province)

Mt. DISEASE Busia Lugari Elgon Vihiga Kakamega Butere Bungoma Teso TOTAL Number of reports expected 466 452 144 897 956 420 596 168 4099 Number of reports received 290 373 134 328 562 378 479 133 2677 % reporting completeness 62% 83% 93% 37% 59% 90% 80% 79% 65% Diarrheal diseases 19823 7346 6115 8998 16583 21363 29620 8005 117853 Tuberculosis 462 142 66 371 574 1195 806 67 3683 Leprosy 13 0 0 2 2 112 0 2 131 Whooping cough 66 2 1 0 123 170 27 1 390 Meningitis 10 7 2 19 70 343 27 6 484 Tetanus 4 0 0 1 0 50 2 0 57 Poliomyelitis 4 0 0 0 2 6 0 0 12 Chicken pox 575 1555 264 403 1089 802 1407 185 6280 Measles 34 24 32 12 74 89 123 13 401 Infectious hepatitis (jaundice) 90 21 4 38 60 71 50 41 375 Mumps 702 517 128 144 1911 472 567 68 4509 16057 4742 100405 Malaria 122860 93341 56207 101483 167039 9 255121 6 6 Gonorrhoea 1133 629 241 854 1356 2980 162 199 7554 Urinary tract infection 4022 3708 1189 2599 6313 11642 12499 1105 43077 Bilharzia (schistosomiasis) 371 12 2 20 23 69 2 63 562 Intestinal worms 8973 3535 2670 7286 8799 12897 7599 4113 55872 Malnutrition 700 193 394 291 977 1235 1765 362 5917 Anaemia 3500 681 505 2076 4154 6646 4942 823 23327 Eye infections 3481 1955 1178 1781 3214 5022 5187 1156 22974 Cataract 137 14 10 20 118 57 128 37 521 Ear infections 2678 1550 968 1598 3567 3244 4406 606 18617 Dis.of circulatory systems 1115 717 51 1541 1206 3756 924 272 9582 1714 Dis.of the respiratory system 52780 41891 23406 32186 58334 75150 74720 3 375610 Pneumonia 3227 2562 3662 19261 13266 6388 32960 1611 82937 Abortion 418 434 99 459 1162 963 1180 170 4885 Dis.of puerperium and child birth 694 184 178 177 360 1022 537 67 3219 Neoplasms 101 10 3 60 388 28 150 5 745 Dis.of blood and blood forming organs 137 65 12 75 347 2143 344 61 3184 Mental disorders 450 301 49 695 600 591 470 87 3243 Dental disorders 2403 837 250 1618 2656 2228 5712 665 16369 Dis.of the skin (incl. Ulcers) 20914 13361 5957 11761 22962 35568 30092 6148 146763 Rheumatism, Joint pains etc 2122 1785 295 1462 2978 9300 3683 547 22172

Annual Report 2003 - 04 179 Mt. DISEASE Busia Lugari Elgon Vihiga Kakamega Butere Bungoma Teso TOTAL Congenital anomalies 124 18 2 54 134 37 160 53 582 Pyrexia of unknown origin (POU) 265 195 77 125 1299 1122 1546 147 4776 Poisoning 247 130 28 156 575 503 255 74 1968 Accidents (incl. Fractures, burns etc) 3892 4837 2786 5763 12417 12948 17600 1765 62008 68 0 39 2227 521 0 0 0 2855 0 0 0 337 13 0 0 0 350 0 0 0 1697 32 0 0 0 1729 All other diseases 16401 14268 7374 15828 34104 32006 44826 5077 169884 19682 41279 9817 222951 TOTAL NEW CASES 274996 7 114244 223478 369402 7 539599 0 3 RE-ATTENDANCES (RE- 3352 VISITS) 51872 24036 13264 29370 87585 56562 120693 1 416903 REFERRALS 1530 2030 570 2193 5858 8185 5436 2221 28023 10276 4437 NO.OF FIRST ATTENDANCES 73583 3 71300 46290 192582 96770 312224 0 939882

Table 122: Out Patient morbidity district summary year 2003 (Coast Province) DISTRICT Kwale Lamu Malindi Taita Tana River Kilifi Mombasa TOTAL Number of reports expected 672 480 996 1032 624 732 2496 7032 Number of reports received 364 141 170 357 103 0 0 1135 % reporting completeness 54% 29% 17% 35% 17% 0% 0% 16% Diarrhoel Diseases 9244 2821 8481 7372 2188 0 0 30106 Tuberculosis 140 112 123 171 11 0 0 557 Leprosy 4 0 1 1 1 0 0 7 Whooping Cough 3 8 1 21 2 0 0 35 Meningitis 1 1 0 2 0 0 0 4 Tetanus 2 0 0 3 0 0 0 5 Poliomyelitis 0 0 2 1 0 0 0 3 Chicken Pox 662 46 325 718 58 0 0 1809 Measles 38 1 20 91 4 0 0 154 Infectious Hepatitis(Jaundice) 556 5 29 29 8 0 0 627 Mumps 214 36 130 1087 29 0 0 1496 Malaria 97190 19401 34075 72387 11832 0 0 234885 Gonorrhoea 913 47 347 96 159 0 0 1562 Urinary Tract Infections 6268 1834 2738 3574 690 0 0 15104 Bilharzia(Schistosomiasis 2248 347 876 411 654 0 0 4536 Intestinal Worms 9486 2485 4238 3200 847 0 0 20256 Malnutrition 425 43 160 116 31 0 0 775 Anaemia 8045 570 2161 867 630 0 0 12273 Eye Infection 2956 908 1622 2904 598 0 0 8988 Cataract 16 19 63 1 7 0 0 106 Ear Infections 2370 775 1399 2228 492 0 0 7264 Dis. Of the Circulatory System 481 392 384 1032 196 0 0 2485 Dis. Of the Respiratory System 47284 12573 22864 48256 6059 0 0 137036 Pneumonia 7561 1281 2936 2090 1261 0 0 15129 Abortion 254 51 189 142 50 0 0 686 Dis of puerperium and Child birth 225 26 472 176 27 0 0 926 Neoplasms 6 13 12 76 5 0 0 112

Annual Report 2003 - 04 180 DISTRICT Kwale Lamu Malindi Taita Tana River Kilifi Mombasa TOTAL Dis of blood forming Organs 71 4 152 108 2 0 0 337 Mental Disorders 274 138 225 541 54 0 0 1232 Dental Disorders 2475 826 636 1505 266 0 0 5708 Dis. Of the Skin (Incl. Ulcers 14887 4741 6502 12130 2553 0 0 40813 Rheumatism, Joint pains etc 1488 451 1153 2788 1024 0 0 6904 Congenital Anomalies 52 16 37 45 6 0 0 156 Pyrexia of unknown Origin (PUO) 312 30 457 60 42 0 0 901 Poisoning 437 27 204 100 13 0 0 781 Accidents (incl.fructures,burns etc) 5458 1015 2365 3587 291 0 0 12716 0 6 156 750 107 0 0 1019 0 0 154 132 35 0 0 321 0 0 266 35 3 0 0 304 All other Diseases 37357 7003 6983 15400 2205 0 0 68948 Total New Cases 259403 58052 102938 184233 32440 732 2496 640294 Re-attendances (Revisits) 41070 8862 31140 23595 4450 0 0 109117 Referrals 1400 252 569 4913 165 0 0 7299 NO. of first Attendances 0 27260 60100 117022 12440 0 0 216822

Table 123: Out Patient morbidity district summary year 2004 (Coast Province) DISTRICT Kwale Lamu Malindi Taita Tana River Kilifi Mombasa TOTAL Number of reports expected 732 480 996 1032 624 792 2496 7152 Number of reports received 301 0 204 0 14 289 0 808 % reporting completeness 41% 0% 20% 0% 2% 36% 0% 11% Diarrhoel Diseases 17183 0 9578 15369 287 15554 0 57971 Tuberculosis 300 0 266 560 10 207 0 1343 Leprosy 3 0 19 6 0 11 0 39 Whooping Cough 3 0 1 10 0 4 0 18 Meningitis 0 0 1 16 0 4 0 21 Tetanus 3 0 1 13 0 6 0 23 Poliomyelitis 0 0 0 0 0 0 0 0 Chicken Pox 1444 0 375 2526 4 499 0 4848 Measles 48 0 23 146 0 27 0 244 Infectious Hepatitis(Jaundice) 560 0 21 30 0 72 0 683 Mumps 364 0 426 617 2 580 0 1989 Malaria 151130 0 36117 147155 1616 73088 0 409106 Gonorrhoea 1324 0 368 695 4 866 0 3257 Urinary Tract Infections 8523 0 4039 6214 50 6157 0 24983 Bilharzia(Schistosomiasis 3374 0 1092 713 60 1329 0 6568 Intestinal Worms 13997 0 3836 5732 154 5665 0 29384 Malnutrition 662 0 162 223 3 377 0 1427 Anaemia 11446 0 1797 1670 37 4351 0 19301 Eye Infection 4725 0 1545 7147 65 3149 0 16631 Cataract 48 0 41 119 0 52 0 260 Ear Infections 3976 0 1671 3794 58 2605 0 12104 Dis. Of the Circulatory System 777 0 811 3712 26 661 0 5987 Dis. Of the Respiratory System 80071 0 22234 110085 811 40783 0 253984 Pneumonia 12914 0 3077 3217 196 5573 0 24977 Abortion 421 0 232 348 1 280 0 1282 Dis of puerperium and Child birth 332 0 817 592 0 398 0 2139 Neoplasms 21 0 26 131 0 17 0 195

Annual Report 2003 - 04 181 DISTRICT Kwale Lamu Malindi Taita Tana River Kilifi Mombasa TOTAL Dis of blood forming Organs 100 0 299 587 2 141 0 1129 Mental Disorders 400 0 280 1338 6 386 0 2410 Dental Disorders 3213 0 1671 3350 36 914 0 9184 Dis. Of the Skin (Incl. Ulcers 26666 0 8517 27286 391 21006 0 83866 Rheumatism, Joint pains etc 2291 0 976 7065 41 2141 0 12514 Congenital Anomalies 64 0 140 116 2 84 0 406 Pyrexia of unknown Origin (PUO) 484 0 1858 154 13 65 0 2574 Poisoning 462 0 662 340 3 151 0 1618 Accidents (incl.fructures,burns etc) 2996 0 3297 9645 24 3919 0 19881 0 0 215 1111 22 924 0 2272 All other Diseases 16672 0 8967 36657 146 19286 0 81728 Total New Cases 366997 0 116793 399064 4072 211626 0 1098552 Re-attendances (Revisits) 32111 0 38417 66858 443 162917 0 300746 Referrals 959 0 1582 4160 21 1523 0 8245 NO. of first Attendances 0 0 70334 271372 861 141060 0 483627

Table 124: Out Patient morbidity district summary year 2003 (North Eastern Province) DISEASE Garissa Wajir Madera Ijara TOTAL Number of reports expected 588 612 408 144 1752 Number of reports received 91 0 0 0 91 % reporting completeness 15% 0% 0% 0% 5% Diarrhoel Diseases 3337 0 0 0 3337 Tuberculosis 104 0 0 0 104 Leprosy 0 0 0 0 0 Whooping Cough 0 0 0 0 0 Meningitis 1 0 0 0 1 Tetanus 0 0 0 0 0 Poliomyelitis 0 0 0 0 0 Chicken Pox 13 0 0 0 13 Measles 66 0 0 0 66 Infectious Hepatitis(Jaundice) 15 0 0 0 15 Mumps 45 0 0 0 45 Malaria 17949 0 0 0 17949 Gonorrhoea 104 0 0 0 104 Uraniry Tract Infections 2439 0 0 0 2439 Bilharzia(Schistosomiasis 234 0 0 0 234 Intestinal Worms 1460 0 0 0 1460 Malnutrition 274 0 0 0 274 Anamea 721 0 0 0 721 Eye Infection 1098 0 0 0 1098 Cataract 112 0 0 0 112 Ear Infections 881 0 0 0 881 Dis. Of the Circulatory System 215 0 0 0 215 Dis. Of the Respiratory System 9935 0 0 0 9935 Pnemonia 5373 0 0 0 5373 Abortion 117 0 0 0 117 Dis of puerperium and Child birth 93 0 0 0 93

Annual Report 2003 - 04 182 DISEASE Garissa Wajir Madera Ijara TOTAL Neoplasms 39 0 0 0 39 Dis of blood forming Organs 14 0 0 0 14 Mental Disorders 100 0 0 0 100 Dental Disorders 497 0 0 0 497 Dis. Of the Skin (Incl. Ulcers 1868 0 0 0 1868 Rheumatism,Joint pains etc 563 0 0 0 563 Congenital Anomalies 33 0 0 0 33 Pyrexia of unknown Origin (PUO) 91 0 0 0 91 Poisoning 23 0 0 0 23 Accidents (incl.fructures,burns etc) 772 0 0 0 772 All other Diseases 5706 0 0 0 5706 Total New Cases 54292 0 0 0 54292 RE-ATTENDANCES (RE-VISITS) 20117 0 0 0 20117 REFERRALS 340 0 0 0 340 NO. OF FIRST ATTENDANCES 7100 0 0 0 7100

Table 125: Out Patient morbidity district summary year 2004 (North Eastern) DISEASE Garissa Wajir Madera Ijara TOTAL Number of reports expected 588 396 408 144 1536 Number of reports received 6 135 0 54 195 % reporting completeness 1% 34% 0% 38% 13% Diarrhoeal diseases 0 4634 0 1121 5755 Tuberculosis 0 34 0 76 110 Leprosy 0 6 0 0 6 Whooping cough 0 89 0 0 89 Meningitis 0 4 0 2 6 Tetanus 0 35 0 0 35 Poliomyelitis 0 1 0 0 1 Chicken pox 0 76 0 0 76 Measles 0 18 0 3 21 Infectious hepatitis (jaundice) 0 28 0 0 28 Mumps 0 184 0 1 185 Malaria 0 15962 0 9718 25680 Gonorrhoea 0 216 0 76 292 Urinary tract infection 0 2702 0 795 3497 Bilharzia (schistosomiasis) 0 126 0 664 790 Intestinal worms 0 2165 0 917 3082 Malnutrition 0 566 0 202 768 Anaemia 0 1125 0 1019 2144 Eye infections 0 886 0 264 1150 Cataract 0 100 0 39 139 Ear infections 0 1061 0 330 1391 Dis.of circulatory systems 0 131 0 147 278 Dis.of the respiratory system 0 13665 0 4133 17798 Pneumonia 0 3014 0 1182 4196 Abortion 0 95 0 41 136 Dis.of puerperium and child birth 0 76 0 109 185 Neoplasms 0 3 0 30 33 Dis.of blood and blood forming organs 0 38 0 21 59

Annual Report 2003 - 04 183 DISEASE Garissa Wajir Madera Ijara TOTAL Mental disorders 0 103 0 67 170 Dental disorders 0 384 0 215 599 Dis.of the skin (incl. Ulcers) 0 1854 0 1018 2872 Rheumatism, Joint pains etc 0 1053 0 137 1190 Congenital anomalies 0 10 0 0 10 Pyrexia of unknown origin (POU) 0 83 0 12 95 Poisoning 0 81 0 28 109 Accidents (incl. Fractures, burns etc) 0 479 0 280 759 All other diseases 0 3392 0 1137 4529 TOTAL NEW CASES 0 54479 0 23784 78263 RE-ATTENDANCES (RE-VISITS) 0 6285 0 0 6285 REFERRALS 0 491 0 0 491 NO.OF FIRST ATTENDANCES 0 7181 0 0 7181

Table 126: Out Patient morbidity district summary year 2003 and 2004 (Nairobi Province) DISEASE 2003 2004 Number of reports expected 4908 4908 Number of reports received 349 193 % reporting completeness 7% 4% DIARRHOEL 23007 14784 TUBERCLOSIS 3623 612 LEPROSY 1 2 WHOOPING COUGH 36 69 MENINGITIS 1098 10 TETANUS 9 2 POLIMYELITIS 1 4 CHICKENPOX 1196 1000 MEASLES 406 73 INFECTIOUS HEPATITIS 671 18 MUMPS 563 701 MALARIA 51931 39516 GONORRHEA 2150 1324 URINARY TRACK INFECTION 23511 8102 BILHARLZIA(SCH) 441 4120 INTERSTINAL WORMS 9031 4883 MALNUTRION 1271 996 ANEAMIA 3774 618 EYE INFECTION 15027 5199 CATACT 1709 129 EAR INFECTI9ON 27392 3132 DIS OF CIRCULATORY SYS 11177 1997 DIS OF RESIRATORY SYS 92293 44386 PNUEMONIA 14699 2720 ABORTION 23063 196 DIS OF PUERPERIUM AND 12788 4173

Annual Report 2003 - 04 184 DISEASE 2003 2004 CHLID BIRTH NEOPLASM 3217 419 DIS OF BLOOD AND BLOOD FORMING ORGANS 6969 606 MENTAL DISODRER 2986 144 DENTAL SIDORDER 3611 2282 DIS OF THE SKIN (UNC ULCERS 21519 12550 RHEUMATISM,JOINT PAINS ETC 15831 4638 CONGINITAL ANOMALIS 9569 185 PYREXIA OF UNKNOWN ORIGIN (PUO) 11047 7805 POISONING 1341 331 ACCIDENT 21238 3333 TYPHOID 3096 1786 HIV/AIDS 7641 113 ALL OTHER DIS 56748 24450 TOTAL NEW CASES 171525 146613 REATTENDANCE(REVISIT) 68212 36235 REFFARRALS 59190 6667 NO.OF FIRST ATTENDANCE 101575 74367

Annual Report 2003 - 04 185 Table 127: Out Patient morbidity district summary year 2003 (Nyanza Province)

DISEASE Kisumu Bondo Siaya Nyando Rachuonyo Homabay Suba Migori Kuria Gucha central Kisii Nyamira TOTAL Number of reports expected 720 600 588 444 648 504 384 708 360 420 672 852 6900 Number of reports received 486 336 446 290 395 347 191 388 171 365 328 538 4281 % reporting completeness 68% 56% 76% 65% 61% 69% 50% 55% 48% 87% 49% 63% 62% Diarrhoeal Diseases 22598 11617 18282 14709 7614 12733 5251 12517 3641 7395 7737 11234 135328 Tuberculosis 2365 816 1014 913 610 557 487 816 12 293 238 219 8340 Leprosy 5 8 20 12 3 7 16 13 1 0 49 147 281 Whooping Cough 546 11 16 5 16 63 100 51 11 3 25 531 1378 Meningitis 78 19 39 20 59 63 12 12 5 3 2 0312 Tetanus 64 0 4 1 3 20 14 0 0 4 3 3116 Poliomyelitis 0 0 0 0 0 00 00 0 0 0 0 Chicken Pox 1357 428 268 222 358 228 105 413 62 494 770 863 5568 Measles 102 99 83 24 78 60 91 259 11 42 86 23 958 Infectious Hepatitis(Jaundice) 90 65 274 32 20 68 102 80 52 32 3 12 830 Mumps 549 116 1825 186 107 134 1754 147 102 31 74 257 5282 Malaria 146952 68555 114668 103400 73713 74418 21466 87176 26867 125646 122479 211510 1176850 Gonorrhoea 1664 1968 2759 1945 1637 2187 1325 2640 376 888 1086 2314 20789 Urinary Tract Infections 9989 3091 6804 2876 3423 3262 1419 5085 756 4582 2372 4683 48342 Bilharzia(Schistosomiasis 217 164 451 90 231 301 307 554 18 39 20 17 2409 Intestinal Worms 9266 6014 8216 6965 4773 3332 1666 5122 2116 6554 7866 12272 74162 Malnutrition 1042 458 948 772 342 972 449 634 194 108 54 109 6082 Anaemia 3170 1458 4427 2326 2660 2016 974 2658 492 1135 503 471 22290 Eye Infection 4759 1722 3107 3360 1758 2158 760 3224 535 2484 2289 5080 31236 Cataract 125 75 268 507 238 152 147 273 7 41 37 43 1913 Ear Infections 2971 1502 3080 3396 1536 1705 781 2836 437 1722 2056 2955 24977 Dis. Of the Circulatory System 2624 333 2772 1229 744 1976 967 2247 73 333 453 164 13915 Dis. Of the Respiratory System 71537 24483 36944 40782 25208 22355 7240 34383 6905 39853 42727 71173 423590 Pneumonia 7160 3145 8217 6448 3957 3910 1206 5957 1623 5420 4897 7795 59735 Abortion 331 326 693 398 347 197 159 494 129 424 219 431 4148 Dis of puerperium and Child birth 231 177 614 140 563 95 127 165 177 362 89 107 2847 Neoplasms 201 38 146 205 34 23 34 132 1 10 83 7 914 Dis of blood forming Organs 266 48 419 148 93 35 101 325 12 129 48 77 1701

Annual Report 2003 - 04 186 DISEASE Kisumu Bondo Siaya Nyando Rachuonyo Homabay Suba Migori Kuria Gucha central Kisii Nyamira TOTAL Mental Disorders 274 43 843 213 524 146 169 255 13 65 90 273 2908 Dental Disorders 4075 1000 5335 1623 1417 1487 1036 2918 453 2625 1456 2139 25564 Dis. Of the Skin (Incl. Ulcers 28088 12010 17913 20344 10358 8270 3207 17626 3317 12263 11247 13829 158472 Rheumatism, Joint pains etc 6839 2044 3385 9983 1133 1495 896 2889 856 3117 3653 4779 41069 Congenital Anomalies 98 14 428 522 39 36 125 241 36 19 150 73 1781 Pyrexia of unknown Origin (PUO) 1522 347 1040 2434 570 675 1030 861 632 497 361 317 10286 Poisoning 427 53 1051 195 137 127 212 165 25 97 101 234 2824 Accidents (incl.fructures,burns etc) 7688 2974 6107 4639 3169 2288 958 3375 1376 8579 5254 10086 56493 0 0 696 112 3402 0 175 1421 208 0 40 1179 7233 0 0 9 0 0 00 1720 5 0 0 434 2168 0 0 0 0 0 00 02 0 0 0 2 All other Diseases 50116 12022 37063 22344 15700 11469 2956 21008 4137 16810 11509 28824 233958 Total New Cases 389386 157243 290674 249424 166574 159020 57824 220692 55699 242099 230126 394664 2617051 RE-ATTENDANCES (RE-VISITS) 180044 29241 47799 51781 8154 41245 9694 38969 13341 0 31436 84750 536454 REFERRALS 8845 1254 14892 3574 354 1405 494 7612 343 0 1362 986 41121 NO. OF FIRST ATTENDANCES 245854 98106 95700 69329 33264 62391 37530 95548 26946 0 79203 294790 1138661

Table 128: Out Patient morbidity district summary year 2004 (Nyanza Province)

Districts Kisumu Bondo Siaya Nyando Rachuony o Homabay Suba Migori Kuria Gucha Kisii central Nyamira TOTAL Number of reports expected 720 600 588 444 648 420 384 744 312 444 804 1020 7128 Number of reports received 314 361 357 310 357 342 210 563 256 294 540 748 4652 % reporting completeness 44% 60% 61% 70% 55% 81% 55% 76% 82% 66% 67% 73% 65% Diarrhoeal diseases 21402 12036 17490 21901 6622 13982 5907 30835 8348 7908 12637 11040 170108 Tuberculosis 6574 687 4287 2867 428 532 171 1460 142 510 1590 254 19502 Leprosy 8 18 4 3 4 14 4 13 0 0 1 0 69 Whooping cough 1080 12 4 1 15 132 24 104 11 5 46 152 1586 Meningitis 62 26 13 89 50 68 7 117 3 17 9 0 461 Tetanus 2 3 6 1 312 9 4 2 3 3 0 48

Annual Report 2003 - 04 187 Districts Kisumu Bondo Siaya Nyando Rachuony o Homabay Suba Migori Kuria Gucha Kisii central Nyamira TOTAL Poliomyelitis 0 7 18 0 2 1 5 15 7 11 0 0 66 Chicken pox 1294 251 397 973 341 471 206 1209 165 1718 2907 2630 12562 Measles 59 99 52 18 21 21 45 89 34 90 92 34 654 Infectious hepatitis (jaundice) 226 121 48 63 23 302 66 80 8 6 42 15 1000 Mumps 961 186 594 3144 320 542 302 587 97 349 400 241 7723 Malaria 143705 74740 128108 169337 64911 80621 27862 129944 62445 123482 150813 222291 1378259 Gonorrhoea 1718 1759 2166 1839 1372 1963 850 15553 1129 971 2033 2047 33400 Urinary tract infection 7650 3504 6653 2849 2918 4587 2060 7057 1791 4471 6499 4569 54608 Bilharzia (Schistosomiasis) 171 260 349 163 208 333 143 741 128 61 1573 2606 6736 Intestinal worms 9313 6747 11029 7327 4405 4266 2276 7354 5238 6289 11799 12570 88613 Malnutrition 891 300 988 1323 587 1019 393 875 323 107 127 1704 8637 Anaemia 2488 1807 4040 2499 2042 2433 963 3347 1125 717 1211 1009 23681 Eye infections 5181 1869 3015 4028 1518 2392 1073 4888 1478 2825 9720 4937 42924 Cataract 212 20 200 185 61 87 174 321 33 61 354 95 1803 Ear infections 3361 1828 2746 3537 1380 2242 1078 4710 1198 2144 4488 3782 32494 Dis.of circulatory systems 2703 339 2550 991 799 2143 215 1952 81 772 4696 306 17547 Dis.of the respiratory system 69310 26835 45088 45903 21282 22201 8760 48894 17983 46578 58855 70080 481769 Pneumonia 5334 2804 7824 8313 3601 5494 1289 10925 9705 5347 9335 14501 84472 Abortion 436 279 691 301 204 240 142 4430 361 410 402 1335 9231 Dis.of puerperium and child birth 217 134 410 146 353 300 161 360 320 501 194 122 3218 Neoplasms 226 35 154 178 31 33 93 133 13 9 69 23 997 Dis.of blood and blood forming organs 206 50 287 85 113 41 59 772 97 33 113 64 1920 Mental disorders 812 58 547 154 246 148 113 244 89 108 971 667 4157 Dental disorders 3663 1498 4030 1502 1072 1722 849 3715 1266 2892 10227 2837 35273 Dis.of the skin (incl. Ulcers) 24903 12078 19269 22281 9239 10989 4400 23857 9080 15106 19046 16041 186289 Rheumatism, Joint pains etc 6005 1728 3927 4161 1333 2090 995 4390 2479 4343 7716 8595 47762 Congenital anomalies 89 56 337 86 46 53 88 308 64 61 53 66 1307 Pyrexia of unknown origin (POU) 3034 584 649 1437 541 748 676 2283 1612 830 470 645 13509 Poisoning 165 65 1079 201 80 66 311 241 499 157 1355 214 4433 Accidents (incl. Fractures, burns etc) 7088 3672 5950 4020 1747 2123 1300 5493 2751 8666 12913 12630 68353 0 0 0 0207 00 0 0 0 0 0 207 0 0 0 021 00 0 0 0 0 0 21

Annual Report 2003 - 04 188 Districts Kisumu Bondo Siaya Nyando Rachuony o Homabay Suba Migori Kuria Gucha Kisii central Nyamira TOTAL 0 0 0 0100 00 0 0 0 0 0 100 All other diseases 52739 11226 20871 28922 16938 21887 2783 33230 8948 27382 27726 32039 284691 TOTAL NEW CASES 383833 167721 295870 260851 143158 186298 65852 350530 139053 264940 360485 323865 3128164 RE-ATTENDANCES (RE-VISITS) 225377 0 0 106861 41974 67300 18532 71289 31387 0 59462 116163 738345 REFERRALS 9196 0 0 12363 1185 3518 235 3236 720 0 2253 13089 45795 NO.OF FIRST ATTENDANCES 178975 0 0 106077 79696 108841 51906 156226 54564 0 101139 228063 1065487

Table 129: Out Patient morbidity district summary year 2003 (Eastern Province)

DISEASE Moyale Tharaka Machakos Meru North Makueni Kitui Mwingi Embu Mbeere Meru South Marsabit Isiolo Cent Meru TOTAL Number of reports expected 276 204 2136 1992 936 1188 744 672 420 732 360 348 768 10776 Number of reports received 123 138 1034 391 650 730 416 189 126 502 16 82 79 4476 % reporting completeness 45% 68% 48% 20% 69% 61% 56% 28% 30% 69% 4% 24% 10% 42% Diarrhoeal Diseases 5323 3012 28094 14793 17051 18367 11139 4225 2150 6235 1981 1109 1271 114750 Tuberculosis 365 47 1370 1349 444 1729 332 932 0 220 121 24 7 6940 Leprosy 0 1 336 4 0 18 2 0 0 38 0 27 0 426 Whooping Cough 0 3 67 10 0 2 1 0 0 3 0 0 0 86 Meningitis 1 5 42 5 1 11 28 2 0 3 0 1 0 99 Tetanus 0 0 123 8 0 1 1 0 0 0 0 0 0 133 Poliomyelitis 0 0 0 0 1 1 0 0 0 0 0 0 0 2 Chicken Pox 18 152 756 969 934 805 612 607 141 476 12 44 254 5780 Measles 0 4 256 25 157 40 21 43 2 61 0 6 29 644 Infectious Hepatitis(Jaundice) 4 17 120 55 43 62 42 1 2 33 2 1 4 386 Mumps 258 150 397 649 384 1058 816 1007 340 488 51 79 106 5783 Malaria 10937 51391 181693 150877 128850 183019 86021 53962 35060 133829 3717 14695 24075 1058126 Gonorrhoea 327 130 2784 861 21787 1449 678 673 194 188 225 203 63 29562

Annual Report 2003 - 04 189 DISEASE Moyale Tharaka Machakos Meru North Makueni Kitui Mwingi Embu Mbeere Meru South Marsabit Isiolo Cent Meru TOTAL Urinary Tract Infections 4429 1215 13456 8457 8235 9414 4043 2314 1046 4844 1019 594 566 59632 Bilharzia(Schistosomiasis 13 25 956 1 1825 980 45 5 19 10 0 64 0 3943 Intestinal Worms 3569 8333 20878 33372 21442 19172 14333 12048 6869 29875 1121 855 4948 176815 Malnutrition 106 70 582 675 220 705 525 57 4 84 10 96 71 3205 Anaemia 1100 357 1282 1013 935 2694 1002 473 245 1552 560 779 91 12083 Eye Infection 1709 1544 8527 9211 6940 4622 4480 4779 933 13082 802 432 706 57767 Cataract 9 17 359 149 91 155 178 3 7 33 3 93 31 1128 Ear Infections 1273 2183 5942 6123 3720 3280 3749 3660 527 2664 476 329 416 34342 Dis. Of the Circulatory System 65 64 3913 609 1119 1928 302 725 5330 553 11 1510 87 16216 Dis. Of the Respiratory System 13467 23710 127503 83090 86348 87788 53026 37549 14745 65814 4805 9186 16446 623477 Pneumonia 5947 2664 13093 15332 6236 6906 2757 7040 1079 17601 1847 1235 1618 83355 Abortion 65 101 845 342 297 637 327 92 44 217 19 44 27 3057 Dis of puerperium and Child birth 28 77 733 254 261 485 265 32 29 506 3 19 190 2882 Neoplasms 3 6 160 59 50 246 37 8 0 47 0 1 24 641 Dis of blood forming Organs 9 23 711 44 151 117 56 55 37 78 4 3 3 1291 Mental Disorders 15 89 1092 946 368 373 437 1198 158 1417 13 40 123 6269 Dental Disorders 703 1292 3248 5222 2497 5724 941 5583 936 5383 249 665 266 32709 Dis. Of the Skin (Incl. Ulcers 1936 7412 39324 19555 33301 21335 14178 10194 4140 32024 535 1070 4440 189444 Rheumatism, Joint pains etc 1493 3075 4813 19324 4076 3043 1346 4015 274 12442 239 982 3212 58334 Congenital Anomalies 8 7 253 66 38 262 21 19 18 94 0 40 13 839 Pyrexia of unknown Origin (PUO) 92 73 936 846 257 1410 341 163 2 79 17 76 36 4328 Poisoning 85 19 476 121 187 231 120 11 1 657 11 245 4 2168 Accidents (incl.fructures,burns etc) 842 2085 13892 11102 10056 7951 4695 5482 1688 5075 702 662 2268 66500 0 0 0 1887 0 0 0 1962 0 77 0 0 241 4167 0 0 0 1313 0 0 0 0 0 365 0 0 2 1680

Annual Report 2003 - 04 190 DISEASE Moyale Tharaka Machakos Meru North Makueni Kitui Mwingi Embu Mbeere Meru South Marsabit Isiolo Cent Meru TOTAL 0 0 0 0 0 0 0 0 0 10 0 0 373 383 All other Diseases 8379 10207 49897 28778 47635 26555 15418 16252 5694 25978 2355 2369 5625 245142

Total New Cases 58306 119560 528909 417496 405937 411146 222315 175171 81714 362135 20910 37578 67715 2908892 RE-ATTENDANCES (RE-VISITS) 6512 18596 75049 64279 117258 131635 41811 49458 7285 84001 1272 2975 13820 613951 REFERRALS 493 814 3180 1592 2743 4013 2023 1925 0 1248 51 2142 489 20713 NO. OF FIRST ATTENDANCES 34585 65939 237306 171812 272387 252199 103734 88346 45057 219005 2049 10894 40074 1543387

Table 130: Out Patient morbidity district summary year 2004 (Eastern Province)

DISEASE Moyale East Meru Machakos Meru North Makueni Kitui Mwingi Embu Mbeere Meru South Marsabit Isiolo Cent Meru TOTAL Number of reports expected 276 204 2136 1992 936 1188 744 672 420 732 360 348 768 10776 Number of reports received 144 167 1488 466 816 774 532 593 339 527 131 133 613 6723 % reporting completeness 52% 82% 70% 23% 87% 65% 72% 88% 81% 72% 36% 38% 80% 62% Diarrhoeal diseases 8363 3559 47033 20197 23739 27444 17430 13244 7148 7781 3070 2189 14491 195688 Tuberculosis 850 30 4655 1334 811 2297 663 2415 246 299 38 30 570 14238 Leprosy 1 0190 2 0 15 2 0 0 0 1 0 93 304 Whooping cough 5 0 40 3 1 6 43 2 0 2 0 9 1 112 Meningitis 0 0 78 17 1 14 12 17 0 1 0 40 2 182 Tetanus 0 0 45 8 2 1 6 1 0 0 04 3 70 Poliomyelitis 0 0 40 0 2 0 1 0 0 0 00 3 46 Chicken pox 14 276 2389 1569 1529 1399 1673 2117 464 738 7 143 1821 14139 Measles 13 1292 61 46 66 33 99 100 72 2 3 109 897 Infectious hepatitis (jaundice) 4 6310 40 45 76 24 25 18 16 6 24 105 699 Mumps 205 132 1227 494 652 1083 337 300 743 129 40 254 858 6454 Malaria 12110 70472 277614 241270 194837 208822 101070 182095 102665 177677 8151 21924 265118 1863825

Annual Report 2003 - 04 191 DISEASE Moyale EastMeru Machakos Meru North Makueni Kitui Mwingi Embu Mbeere Meru South Marsabit Isiolo Cent Meru TOTAL Gonorrhoea 286 100 3998 753 1045 1171 923 1394 341 155 269 389 589 11413 Urinary tract infection 4540 1386 23585 7757 12355 11712 4704 6311 2554 7579 729 1306 7186 91704 Bilharzia (Schistosomiasis) 3 29 2035 16 1727 615 151 145 84 54 0 182 155 5196 Intestinal worms 4015 13577 37739 55916 27680 26443 18945 40257 19125 34812 1517 2014 55634 337674 Malnutrition 64 52 1287 900 255 762 316 833 141 88 238 246 247 5429 Anaemia 953 371 3955 1255 914 1372 1398 1998 1009 1349 491 879 1581 17525 Eye infections 1772 2039 14504 12330 8019 6551 5859 10780 2553 8147 1214 1559 6575 81902 Cataract 12 23 1021 168 140 239 205 931 217 82 44 87 137 3306 Ear infections 1437 2549 10598 8744 5289 3106 2996 7781 1263 2981 573 919 5682 53918 Dis.of circulatory systems 111 58 8619 509 1609 11018 1710 5196 740 1167 98 741 3660 35236 Dis.of the respiratory system 18986 36861 213264 142066 117680 127611 72383 113840 50091 97783 9560 16102 177680 1193907 Pneumonia 7365 2181 23748 22005 9180 7374 3759 21974 5177 17301 1979 2791 14761 139595 Abortion 70 105 1605 570 398 533 328 351 127 160 50 47 253 4597 Dis.of puerperium and child birth 15 81 2023 471 390 740 396 100 141 689 98 39 192 5375 Neoplasms 1 0413 56 41 117 90 35 13 37 5 4 60 872 Dis.of blood and blood forming organs 23 10 1466 50 183 92 133 294 31 125 27 2 501 2937 Mental disorders 9 92 2878 1151 545 535 762 3013 216 1251 81 150 2013 12696 Dental disorders 765 1221 9183 5945 5260 5404 1602 15442 1552 6711 281 880 7911 62157 Dis.of the skin (incl. Ulcers) 1904 9120 59801 27696 38853 33359 20523 39802 14711 27013 1538 2848 45862 323030 Rheumatism, Joint pains etc 2168 6146 8649 28367 4833 2963 2184 15609 1760 13918 837 1561 48875 137870 Congenital anomalies 297 7 451 54 37 49 108 223 10 181 7 11 379 1814 Pyrexia of unknown origin (POU) 86 41 1452 955 416 466 227 1031 52 147 131 476 744 6224 Poisoning 156 36 936 224 166 218 246 480 82 69 80 145 277 3115 Accidents (incl. Fractures, burns etc) 726 2408 21513 17838 10426 10578 6010 17752 4214 5756 578 1655 16338 115792 128 0 66 66 66 36 66 7299 66 0 86 0 2085 9964 74 15 10180 3992 894 164 48 0 1726 0 35 0 105 17233

Annual Report 2003 - 04 192 DISEASE Moyale EastMeru Machakos Meru North Makueni Kitui Mwingi Embu Mbeere Meru South Marsabit Isiolo Cent Meru TOTAL 0 0 0 431 0 0 0 0 41 0 0 0 4073 4545 All other diseases 10724 13330 67042 46113 55774 38374 24661 44526 19288 37673 4914 5210 67482 435111 TOTAL NEW CASES 78311 151070 851211 640790 509480 522042 244604 557712 238709 449545 36668 64863 754211 5099216 RE-ATTENDANCES (RE- VISITS) 7453 28091 181105 69106 118844 146708 79483 138817 27209 131830 0 983 144043 1073672 REFERRALS 449 662 10162 15227 2849 7203 3862 11306 391 1220 0 62 6234 59627 NO.OF FIRST ATTENDANCES 41743 90632 466372 202262 297362 308721 119630 318621 124285 263143 0 2139 453939 2688849

Table 131: Out Patient morbidity district summary year 2003 (Rift Valley Province)

DISEASE Laikipia Marakwet U-Gishu Bomet Samburu Narok Keiyo Transmara Kericho Nakuru Number of reports expected 744 528 1236 744 516 648 420 552 1020 1836 Number of reports received 112 101 856 65 104 376 122 269 562 1079 % reporting completeness 15% 19% 69% 9% 20% 58% 29% 49% 55% 59% Diarrhoeal Diseases 3906 2575 15711 1532 3475 9086 2817 7386 10825 31011 Tuberculosis 9 112 850 8 130 44 65 217 182 1356 Leprosy 0 0 0 0 0 2 0 0 0 7 Whooping Cough 0 2 4 0 0 0 0 2 11 4 Meningitis 4 4 69 3 3 7 0 4 9 15 Tetanus 1 1 51 0 0 1 0 2 1 1 Poliomyelitis 0 0 0 0 0 0 0 0 0 0 Chicken Pox 620 162 2452 316 72 426 315 684 1184 4446 Measles 3 3 200 8 5 87 6 20 86 278 Infectious Hepatitis(Jaundice) 5 3 93 0 13 7 0 9 11 77 Mumps 254 46 359 22 122 421 30 143 597 1838 Malaria 12791 6056 169044 7677 8834 32591 12875 70581 106658 172812 Gonorrhoea 98 113 1074 76 771 1173 107 532 1354 2341 Urinary Tract Infections 970 348 6645 554 641 3905 737 2125 4195 12310 Bilharzia(Schistosomiasis 2 2 79 4 11 204 5 0 155 269

Annual Report 2003 - 04 193 DISEASE Laikipia Marakwet U-Gishu Bomet Samburu Narok Keiyo Transmara Kericho Nakuru Intestinal Worms 2457 534 4666 1341 603 2839 985 3826 8677 19387 Malnutrition 46 38 412 18 114 168 203 137 336 889 Anaemia 140 11 1376 45 216 278 76 458 760 1347 Eye Infection 1277 517 8608 459 1417 3027 1306 2888 3197 14997 Cataract 23 10 767 14 71 97 9 71 79 379 Ear Infections 626 366 4412 277 819 1694 399 1018 2360 6715 Dis. Of the Circulatory System 426 26 860 27 539 145 23 172 284 4077 Dis. Of the Respiratory System 24670 6563 84022 4865 12481 34419 14027 27221 70865 175156 Pneumonia 1238 1565 12359 560 2131 8764 1770 5210 4460 19413 Abortion 107 63 994 46 128 316 74 208 221 1528 Dis. of puerperium and Child birth 37 21 459 91 165 493 68 328 143 1535 Neoplasms 7 0 279 3 31 7 9 10 37 152 Dis of blood forming Organs 46 7 301 17 348 101 16 38 207 682 Mental Disorders 150 33 743 32 83 136 55 146 618 1872 Dental Disorders 275 276 8897 247 607 1163 713 643 1719 12711 Dis. Of the Skin (Incl. Ulcers 5551 2002 23717 3047 3147 7758 3684 9639 20011 53584 Rheumatism, Joint pains etc 1371 491 4998 316 1016 1893 1275 1239 3539 9564 Congenital Anomalies 12 10 116 0 10 22 4 25 87 286 Pyrexia of unknown Origin (PUO) 146 34 749 180 109 221 37 54 247 1502 Poisoning 15 32 1205 39 35 82 46 87 63 711 Accidents (incl.fructures,burns etc) 2127 1377 19866 766 1442 3210 3123 3756 9678 19648 Typhoid Fever 95 55 1784 132 0 1985 10 0 2820 5870 Amoebiasis 30 502 439 0 0 0 0 0 0 0 All other Diseases 6877 3193 55537 3241 3270 11530 4795 6372 27081 91695 Total New Cases 66412 27153 434285 25963 42859 128302 49664 145251 282757 670465 RE-ATTENDANCES (RE-VISITS) 12588 6320 81756 3076 14840 14350 13032 23831 61136 44166 REFERRALS 695 108 4867 210 234 0 159 462 2021 5566 NO. OF FIRST ATTENDANCES 6556 16638 250710 22571 39238 0 11262 117808 146571 92878

Annual Report 2003 - 04 194 Out Patient morbidity district summary year 2003 (Rift Valley Province) DISEASE Turkana Nsouth Nnorth Wpokot Baringo T-Nzoia Koibatek Bureti Kajiado Totals Number of reports expected 912 708 444 732 972 780 312 552 1308 14964 Number of reports received 459 235 33 371 405 526 243 492 0 6410 % reporting completeness 50% 33% 7% 51% 42% 67% 78% 89% 0% 43% Diarrhoeal Diseases 14242 16156 5540 11958 8911 19593 5749 13087 0 183560 Tuberculosis 693 160 52 264 94 166 23 233 0 4658 Leprosy 11 0 0 1 1 15 0 30 0 67 Whooping Cough 84 5 0 3 0 3 0 4 0 122 Meningitis 8 5 1 15 3 13 1 13 0 177 Tetanus 53 1 2 0 2 3 0 0 0 119 Poliomyelitis 0 0 0 0 0 0 0 0 0 0 Chicken Pox 706 996 396 429 909 2107 1236 2711 0 20167 Measles 30 100 47 34 25 151 10 59 0 1152 Infectious Hepatitis(Jaundice) 61 10 1 1 51 27 3 6 0 378 Mumps 71 128 74 211 289 118 360 424 0 5507 Malaria 77681 147812 56304 110235 34690 182782 37385 112801 0 1359609 Gonorrhoea 925 612 143 448 215 917 719 843 0 12461 Urinary Tract Infections 2088 2349 1512 3957 1685 4252 1277 4381 0 53931 Bilharzia(Schistosomiasis 42 27 21 32 33 35 82 2 0 1005 Intestinal Worms 2543 10344 3869 3576 2692 6706 2848 12387 0 90280 Malnutrition 436 217 114 215 1292 796 134 163 0 5728 Anaemia 1250 891 278 1672 414 1280 351 491 0 11334 Eye Infection 7210 4646 1360 2706 2848 2973 2169 3482 0 65087 Cataract 206 30 102 86 69 72 272 47 0 2404 Ear Infections 2574 3095 796 2025 1527 3426 2045 2956 0 37130 Dis. Of the Circulatory System 228 83 450 167 435 289 634 910 0 9775 Dis. Of the Respiratory System 43494 97352 19741 45236 32569 75384 41552 81962 0 891579 Pneumonia 6414 4993 1236 6532 3953 5490 3592 4317 0 93997 Abortion 283 281 103 665 113 594 353 268 0 6345 Dis. of puerperium and Child birth 249 279 116 341 90 327 156 196 0 5094 Neoplasms 62 11 28 95 8 58 33 233 0 1063 Dis. Of blood and blood forming organs 122 80 27 10 60 453 70 137 0 2722 Mental Disorders 78 231 234 68 88 188 340 373 0 5468 Dental Disorders 890 3315 1613 1198 1489 4254 2565 3479 0 46054 Dis. Of the Skin (Incl. Ulcers 9239 18471 8800 7514 7126 19242 8050 39762 0 250344 Rheumatism, Joint pains etc 1802 5238 847 654 3006 1557 2943 4846 0 46595

Annual Report 2003 - 04 195 Out Patient morbidity district summary year 2003 (Rift Valley Province) DISEASE Turkana Nsouth Nnorth Wpokot Baringo T-Nzoia Koibatek Bureti Kajiado Totals Congenital Anomalies 58 19 110 39 48 96 160 64 0 1166 Pyrexia of unknown Origin (PUO) 557 421 74 88 188 764 642 793 0 6806 Poisoning 381 92 74 68 78 282 485 134 0 3909 Accidents (incl.fructures,burns etc) 3814 7823 4676 4587 4978 9472 4654 7333 0 112330 Typhoid Fever 0 0 0 0 0 0 1722 319 0 14792 Amoebiasis 0 0 0 0 0 0 0 2 0 973 All other Diseases 19131 67177 5413 19059 8306 35629 7947 36512 0 412765 Total New Cases 182957 362121 111488 224131 118376 343253 130562 335778 0 3681777 RE-ATTENDANCES (RE-VISITS) 49109 198010 0 77173 14511 44600 23002 118501 0 800001 REFERRALS 1321 3735 0 2860 795 3566 3125 4928 0 34652 NO. OF FIRST ATTENDANCES 125118 128652 0 123648 42728 266293 63501 269990 0 1724162

Table 132: Out Patient morbidity district summary year 2004 (Rift Valley Province) DISEASE(Out Patient morbidity district summary year 2004 (Rift Valley Province) hu Gis - Laikipia Marakwet U Bomet Samburu Narok Keiyo Transmar a Kericho Nakuru Number of reports expected 528 744 1200 532 516 648 420 552 1020 1836 Number of reports received 370 230 835 432 229 446 218 460 634 921 % reporting completeness 70% 31% 70% 81% 44% 69% 52% 83% 62% 50% Diarrhoeal diseases 9437 15172 15200 13401 9296 12880 6315 16540 15283 27102 Tuberculosis 120 35 1005 350 292 130 71 230 1584 633 leprosy 1 0 0 0 4 0 0 26 10 2 Whooping cough 16 0 9 5 0 5 1 14 15 97 Meningitis 2 1 63 13 2 6 5 22 16 15 Tetanus 0 1 5 1 0 0 0 96 21 74 Poliomyelitis 0 0 4 0 0 0 0 0 0 114 Chicken pox 804 1591 4064 1126 347 956 1138 2391 2334 6139 Measles 30 43 103 60 44 82 39 90 140 314 Infectious Hepatitis(Jaundice) 8 19 52 62 45 3 1 15 27 607 MUMPS 292 1623 1015 1095 305 393 65 478 1638 12215 Malaria 35715 55578 149009 60100 31589 55663 35279 184045 105353 165065 Gonorrhoea 342 661 1074 1063 1452 2006 322 891 1341 3710

Annual Report 2003 - 04 196 DISEASE(Out Patient morbidity district summary year 2004 (Rift Valley Province) hu Gis - Laikipia Marakwet U Bomet Samburu Narok Keiyo Transmar a Kericho Nakuru Urinary tract Infection 1883 4118 8314 3851 2334 4673 1997 5863 5048 11172 Bilharzia(Schistosomiasis) 12 80 295 169 41 119 11 16 457 2028 Intestinal worms 1634 13210 5831 13599 2013 5333 2904 6374 12387 16986 Malnutrition 95 86 497 313 343 139 240 399 544 2634 Anaemia 81 242 1122 379 388 304 99 840 757 2357 Eye infection 2232 5035 9438 3277 4593 3834 3449 3311 7195 11596 Cataract 46 121 1732 143 125 37 37 58 456 1954 Ear infection 1889 2323 6609 2023 2545 2442 2130 3416 3944 8239 Dis. Of circulatory system 105 1735 1141 1237 1326 385 35 440 5355 11838 Dis.of the respiratory system 39718 106555 104974 50423 41642 53102 47232 91789 79668 286023 Pneumonia 7403 4147 13840 4998 8316 9962 6102 6368 6321 32231 Abortion 301 261 1016 299 343 369 212 1558 397 2780 Dis.of pueperium and childbirth 102 265 585 289 406 610 150 448 345 1098 Neoplasm 27 20 312 25 46 33 19 37 65 227 Dis. Of blood and blood forming organs 40 168 472 84 1051 175 43 85 426 548 Mental disorders 99 646 950 448 200 195 174 217 1144 2072 Dental disorders 2085 3690 8999 1904 1512 1412 1688 2804 7011 10405 Dis. Of the skin(inc.ulcers) 8417 22513 26820 18425 9168 12496 9494 21038 21716 45161 Rheumatism, Joint pains etc 2208 5555 5902 2469 2743 3836 3552 2089 5393 14076 Congenital Anomalies 34 124 276 89 17 42 13 118 224 1375 Pyrexia of unknown origin(PUO) 117 430 620 874 201 264 138 621 1322 1187 Poisoning 73 360 564 175 181 122 73 438 1145 1187 Accidents(incl.fractures,burns etc) 6789 9436 16186 6093 4593 5285 8943 11905 9754 18463 22 0 0 0 34 0 0 0 0 0 166 0 0 0 0 169 56 162 456 671 0 0 0 0 0 113 0 3 138 0 All other diseases 15184 32518 49320 23200 12533 14344 16448 32922 35785 112491 TOTAL NEW CASES 137529 288362 437418 212062 140070 191919 148475 398157 335215 814886 RE-ATTENDANCE(RE-VISITS) 22742 75194 90924 27106 42897 40681 19795 48453 85314 140592 REFERRALS 648 2910 4015 25705 12343 262 219 4535 11311 36006 NO.OF FIRST ATTENDANCES 98934 83166 304825 155234 95095 2797 5267 257088 209310 254922

Annual Report 2003 - 04 197 Out Patient morbidity district summary year 2004 (Rift Valley Province) Nzoia -

DISEASE Turkana Nsouth Nnorth Wpokot Baringo T Koibatek Bureti Kajiado Totals Number of reports expected 912 708 517 732 960 780 336 556 1308 14805 Number of reports received 620 537 361 406 739 503 279 527 1045 9792 % reporting completeness 68% 76% 70% 55% 77% 64% 83% 95% 80% 66% Diarrhoeal diseases 6844 14873 10765 13096 20010 15338 6680 18652 17237 264121 Tuberculosis 180 212 145 389 877 491 66 156 625 7591 leprosy 0 0 8 1 1 0 0 0 12 65 Whooping cough 3 3 4 38 1 67 3 5 19 305 Meningitis 2 2 2 20 23 10 1 3 15 223 Tetanus 3 0 1 0 14 9 0 0 0 225 Poliomyelitis 0 1 2 0 8 46 0 2 2 179 Chicken pox 682 1566 1069 626 2009 709 1005 3003 1372 32931 Measles 29 156 75 26 12 7 48 74 125 1497 Infectious Hepatitis(Jaundice) 3 9 11 8 28 33 3 7 78 1019 MUMPS 186 622 571 269 1343 138 304 2824 638 26014 Malaria 64135 168920 139799 90782 71383 74194 39032 103681 62987 1692309 Gonorrhoea 192 402 519 384 361 962 422 649 2419 19172 Urinary tract Infection 1825 3143 3338 5047 3083 2503 1364 4705 7546 81807 Bilharzia(Schistosomiasis) 26 24 76 7 81 189 6 21 85 3743 Intestinal worms 4329 12135 11078 2796 5889 2403 2872 20200 5721 147694 Malnutrition 86 194 149 150 745 438 37 129 273 7491 Anaemia 205 1482 915 868 615 763 196 341 1844 13798 Eye infection 3010 5780 4332 2256 5373 10015 2547 4328 5958 97559 Cataract 12 95 41 20 87 79 32 62 112 5249 Ear infection 1419 4394 3055 2246 2928 2633 1943 3444 3283 60905 Dis. Of circulatory system 103 338 386 325 818 76 148 1035 1754 28580 Dis.of the respiratory system 31052 101471 87197 50094 95630 46802 54779 91025 53222 1512398 Pneumonia 4663 7124 5735 7300 7731 6528 6504 4151 13661 163085 Abortion 210 327 307 781 472 260 161 313 591 10958 Dis.of pueperium and childbirth 167 396 300 296 288 153 159 270 490 6817 Neoplasm 23 47 35 19 26 19 34 96 62 1172

Annual Report 2003 - 04 198 Out Patient morbidity district summary year 2004 (Rift Valley Province) Nzoia -

DISEASE Turkana Nsouth Nnorth Wpokot Baringo T Koibatek Bureti Kajiado Totals Dis. Of blood and blood forming organs 27 69 173 37 99 53 30 129 172 3881 Mental disorders 81 424 416 190 197 93 182 460 169 8357 Dental disorders 542 4821 3504 1546 1922 1137 1695 5239 1495 63411 Dis. Of the skin(inc.ulcers) 11789 22064 18276 10408 14726 9804 11099 32418 11498 337330 Rheumatism, Joint pains etc 1216 7799 4904 1028 6710 1782 3841 8640 3709 87452 Congenital Anomalies 12 20 190 12 100 96 17 54 112 2925 Pyrexia of unknown origin(PUO) 65 542 277 136 333 662 121 1297 550 9757 Poisoning 232 177 292 77 199 364 47 242 465 6413 Accidents(incl.fractures,burns etc) 3776 11425 8825 6672 9923 3981 6446 8131 5347 161973 0 38 0 0 0 0 0 0 4 98

47 287 50 260 0 27 71 0 249 2671 0 0 0 7 0 35 0 0 59 355

All other diseases 6786 38685 64174 13857 21148 15327 10026 33236 18307 566291 TOTAL NEW CASES 143962 410067 371715 212074 275193 198226 151921 349022 222267 5438540 RE-ATTENDANCE(RE-VISITS) 23539 177727 130913 73372 30943 41934 22240 82932 62714 1240012 REFERRALS 262 6651 2677 1908 38456 883 679 38442 27125 215037 NO.OF FIRST ATTENDANCES 107120 169507 165703 120057 66123 117426 101675 183761 16579 2514589

Annual Report 2003 - 04 199 13. HOSPITAL ADMINISTRATIVE STATISTICS

The Ministry of Health and partner agencies, (NGOs, Mission) together with private practitioners runs a total of 5,170 health facilities out of which 41% are manned by government of Kenya, 15% by NGOs and Mission and 44% by private and community. For the hospital administration to effectively allot resources to run in-patient services, it should be done based on Hospital administrative statistics which is obtained in hospitals on daily basis from the Daily Bed Returns (DBR). The data below shows some of the hospitals reporting hospital administrative statistics. It was expected that all facilities admitting patients should have submitted the report but facilities without Health Records and Information officers could not report and therefore recommend that major hospitals in the country should employ this officer’s in-order to get complete and quality reports. These are: Hospitals (4%), Nursing Homes (4%), Sub-district Hospital (1%) and Health Centres (13%) of the total health facilities in the country. Averagely, most of our hospitals had % bed occupancy of over 85%. Some had patients sharing beds and therefore had none of their beds with a Turnover interval i.e. Zero or negative with the cumulative number of patients attended to in the wards totalling to 3,808, 335 reported. The Average Length of Stay (ALOS) was 7 days with average occupancy of 10, 405 patients.

Annual Report 2003 - 04 200 Table 133: National Summary Hospital Administriatve Statistics 2004

PROVINCE BEDS COTS ADM DISCH DEATHS ABSC W/PEOPLE OBD ABD % OCC ALOS AV. OCC. TOB TOI NAIROBI 2454 20 77338 66339 9103 237 3342 874173 831942 105% 12 2388 31 -1 COAST 1518 285 45332 40649 3006 597 109875 327831 377354 87% 7 896 25 1 CENTRAL 2354 395 126461 114210 7275 1046 119837 726011 898919 81% 6 1984 45 1 RIFT VALLEY 3108 202 96986 88421 6366 833 166634 725809 918892 79% 8 1983 29 2 EASTERN 2028 327 84593 75129 4831 1171 101146 611288 828558 74% 8 1670 34 3 NORTH EASTERN 263 4 3637 2850 152 103 5804 21370 28443 75% 7 58 12 2 NYANZA 1080 56 60082 50113 4120 439 45627 323961 324934 100% 6 885 48 0 WESTERN 743 109 36211 30789 1440 888 38415 197892 282853 70% 6 541 39 3 TOTAL 13548 1398 530640 468500 36293 5314 590680 3808335 4491895 85% 7 10405 34 1.3

Table 134: Central Province Administriatve Statistics 2004

HOSPITAL BEDS COTS ADM DISCH DEATHS ABSC W/PEOPLE OBD ABD % OCC ALOS AV. OCC. TOB TOI NYERIPGH 329 72 25066 21797 1099 120 20593 156063 146766 106% 7 426 57 -0.4 KIAMBU DH 338 45 13438 11977 720 114 17409 91483 140178 65% 7.1 250 33.4 3.8 KIRINYAGA 198 45 14226 13697 758 54 8793 87492 88695 99% 6 240 60 0.1 NYAHURURU 98 52 10290 9157 713 182 10930 56269 54021 104% 6 154 67 -0.2 ACK MT KENYA 40 0 542 525 27 1 87 2651 6000 44% 5 7 14 6.1 THIKA 260 0 22113 19607 1223 274 26086 107614 94900 113% 5 294 81 -0.6 KARATINA 216 12 9647 8915 521 15 10791 56231 83220 68% 6 154 41 2.9 MURANGA 154 24 5312 4322 684 91 0 47534 71370 67% 9 130 29 4.7 PCEA KIKUYU 0 0 0 0 0 0 0 0 00 0 0 0 0 MKURUEINI 78 0 2487 2268 219 4 3592 15559 28470 55% 6 43 32 5.2 MURIRANJAS 64 8 2606 2623 139 17 1869 9738 26280 37% 4 27 39 6.0 MARAGUA 212 60 2482 2194 183 15 2658 9728 8274 118% 4 27 9 -0.6 TIGONI 51 0 3226 2950 215 78 4910 13315 18615 72% 4 36 64 1.6 KATUNDU 98 23 5892 6270 350 27 5718 26127 44165 59% 4 71 55 2.7 OLKALAU 144 47 4807 4068 277 5 4882 36251 69715 52% 8 99 23 7.7 MWEA MISS 0 0 0 0 0 0 0 0 00 0 0 0 0 NASARETH MISS 0 0 0 0 0 0 0 0 00 0 0 0 0 KIMBIMBI 46 4 2699 2425 138 49 1519 9956 18250 55% 4 27 52 3.2 OTHAYA 5 0 611 529 0 0 0 1,172 1,830 64% 2 3 106 1.2 MT. KENYA SDH 17 2 482 354 9 0 35 2438 6954 35% 7 7 19 12.4 KARURI RHTC 6 1 535 532 0 0 1046 1046 2562 41% 2 3 76 2.8 TOTAL 2354 395 126461 114210 7275 1046 120918 730667 910265 80% 6 2002 45 1.5

Annual Report 2003 - 04 201 Table 135: Nairobi Province Hospital Administriatve Statistics 2004

HOSPITAL BEDS COTS ADM DISCH DEATHS ABSC W/PEOPLE OBD ABD % OCC ALOS AV. OCC. TOB TOI

KNH 1806 0 71424 63690 8028 0 0 703518 655354 107% 10 1922 40 -0.7

SPINAL 0 0 0 0 0 0 0 0 0 0 0 0 0 0

MATER 0 0 0 0 0 0 0 0 0 0 0 0 0 0

AGA KHAN 0 0 0 0 0 0 0 0 0 0 0 0 0 0

MBAGATHI 168 20 4882 3436 1394 26 9896 46524 68620 68% 10 127 26 4.6

MATHARE 480 0 3734 149 37 298 0 227263 174584 130% 470 621 1 -109

NAIROBI 0 0 0 0 0 0 0 0 0 0 0 0 0 0

PUMWANI 0 0 0 0 0 0 0 0 0 0 0 0 0 0

EQUATOR 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NAIROBI WEST 0 0 0 0 0 0 0 0 0 0 0 0 0 0

MPSHAR 0 0 0 0 0 0 0 0 0 0 0 0 0 0

ST MARY 0 0 0 0 0 0 0 0 0 0 0 0 0 0

ST JAMES 0 0 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 2454 20 80040 67277 9459 324 9896 977305 899426 109% 13 2670 31 -1.0

Annual Report 2003 - 04 202 Table 136: North Eastern Province Hospital Administriatve Statistics 2004 % AV. HOSPITAL BEDS COTS ADM DISCH DEATHS ABSC W/PEOPLE OBD ABD OCC ALOS OCC. TOB TOI

GARISSA PGH 152 0 2462 1828 113 84 3427 15139 18240 83% 7 41 13 2 IJARA DH 18 0 721 624 18 0 0 5234 6449 81% 8 14 36 2 WAJIR DH 98 4 683 593 26 19 2377 2377 5502 43% 4 7 6 5 MANDERA DH 0 0 0 0 0 0 0 0 0 00 0 0 0

TOTAL 268 4 3866 3045 157 103 5804 22750 30191 75% 7 84 12 2.3

Table 137: Eastern Province Administriatve Statistics 2004 % AV. HOSPITAL BEDS COTS ADM DISCH DEATHS ABSC W/PEOPLE OBD ABD OCC ALOS OCC. TOB TOI EMBUPGH 417 124 15437 13537 1023 488 18936 138756 198006 70% 9 379 28 3.9 MACHAKOS GH 327 53 20887 18638 1079 53 13360 144494 139080 104% 7 395 52 -0.3 KARURUMO RHTC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MATUU SDH 15 11 1041 1027 119 12 1233 5521 9516 58% 5 15 45 3.4 KITUI DH 156 36 8765 7158 602 15 0 75917 70272 108% 10 207 40 -0.7 KANGUDO SDH 118 32 2142 1705 329 0 0 26722 54900 49% 13 73 14 13.9 KATHIANI SDH 127 3 2593 2424 0 0 7051 29298 47580 62% 12 80 19 7.5 MWINGI DH 80 0 3341 2781 271 11 0 23612 29280 81% 8 65 38 1.9 MAKINDU SDH 64 7 2766 2494 293 0 9464 13831 25986 53% 5 38 39 4.4 MAKUENI DH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SIAKAGO 0 0 0 0 0 0 0 0 0 0 0 0 0 0 RUNYEJES 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MBEERE DH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MUTHINE 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MAKINDUNI 28 2 553 455 5 15 816 2284 10980 21% 5 6 16 18.3 MERU EAST 20 0 1782 1693 39 37 2264 5715 7320 78% 3 16 88 0.9 MBOONI SDH 30 4 901 966 71 4 2844 3198 12444 26% 3 9 31 8.9 MERU SOUTH 86 23 8785 7870 504 362 23394 63647 39894 160% 7 174 80 -2.7 MIATHENE 54 7 2047 1886 66 59 2417 4096 22326 18% 2 11 33 9.1 MERU NORTH 40 6 3471 3525 0 0 0 7047 16836 42% 2 19 77 2.8 MERU 268 13 4847 3710 450 0 9523 46248 102846 45% 11 126 15 13.6

Annual Report 2003 - 04 203 % AV. HOSPITAL BEDS COTS ADM DISCH DEATHS ABSC W/PEOPLE OBD ABD OCC ALOS OCC. TOB TOI CENTRAL KITHONGO 0 0 0 0 0 0 0 0 0 0 0 0 0 0 KANYAKINE 78 4 3545 3467 70 0 5146 10482 26176 40% 3 29 43 4.4 ISIOLO 128 35 3101 2845 97 71 4349 20048 44139 45% 7 55 18 8.0 MOYALE 82 2 1880 1743 75 30 6690 11334 24532 46% 6 31 22 7.1 MARSABIT 86 0 1444 1334 67 14 710 7331 23434 31% 5 20 16 11.4 ISHIARA 69 2 3875 3423 143 337 10836 27727 25491 109% 76 TOTAL 2273 362 89328 79258 5160 1171 108197 667308 931038 72% 81823 32 3.1

Table 138: Nyanza Hospital Administriatve Statistics 2004 % AV. HOSPITAL BEDS COTS ADM DISCH DEATHS ABSC W/PEOPLE OBD ABD OCC ALOS OCC. TOB TOI NNPGH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 KSM DH 184 3 13156 8289 1075 108 13653 58255 51300 114% 6 312 51 -0.7 CHULAIMBO RHTC 19 0 420 414 3 3 0 1149 589 195% 3 60 22 -1.3 AGA KHAN HOSP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BONDO DH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SIAYA DH 188 9 9030 7539 591 281 4095 55561 49397 112% 7 282 43 -0.7 YALA SDH 27 1 2901 2923 101 47 2041 6868 8512 81% 2 245 110 0.5 PAP ONDITI DH 114 0 764 690 67 0 0 2600 3477 75% 3 23 7 1.2 MUHORONI SDH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NYAMIRA DH 202 43 8302 7797 582 0 5442 40604 89670 45% 5 166 34 5.9 KISII DH 346 0 25509 22461 1701 0 20396 158924 121989 130% 7 459 70 -1.5 KEUMBU SDH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 OGEMBO DH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TABAKA MISS 0 0 0 0 0 0 0 0 0 0 0 0 0 0 KEHANCHA DH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MIGORI DH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 OMBO MISS 0 0 0 0 0 0 0 0 0 0 0 0 0 0 HOMA-BAY DH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SINDO DH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 OYUGIS DH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 GENDIA MISS 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TOTAL 1080 56 60082 50113 4120 439 45627 323961 324934 100% 6 285 48 0.0

Annual Report 2003 - 04 204 Table 139: Coast Province Hospital Administriatve Statistics 2004 % AV. HOSPITAL BEDS COTS ADM DISCH DEATHS ABSC W/PEOPLE OBD ABD OCC ALOS OCC. TOB TOI

ST. LUKES 52 0 104 86 4 0 0 583 1612 0 6 2 2 11 MALINDI 117 16 6695 6467 558 190 16174 62752 46533 135% 9 171 54 -2 HOLA 89 0 1885 1598 76 48 4011 22920 23886 96% 13 63 19 1 NGAO 36 1 1372 1336 42 4 2002 5321 13843 38% 4 15 37 6 COASTPGH 496 126 17129 15904 1377 182 35659 90583 112582 80% 5 247 28 1 PORTRITZE 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TAVETA 100 0 502 498 20 7 608 1965 5900 33% 4 5 5 7 MOI VOI 92 17 3732 3191 254 73 12123 25245 33444 75% 7 69 32 2 WESU 59 0 1201 1069 102 14 728 6834 14455 47% 6 19 20 6 KILIFI 168 45 4310 3224 207 15 28100 54436 38493 141% 16 149 16 -5 MARIAKANI 27 0 331 295 7 1 338 722 1461 49% 2 2 11 2 MSAMBWENI 140 5 3430 2974 180 17 0 25083 30207 83% 8 69 22 2 AGA KHAN 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TIWI 17 4 1230 993 11 2 1860 2788 5733 49% 3 8 48 3 KINANGO 80 29 1913 1335 90 44 3673 22525 35783 63% 15 62 13 9 KWALE 45 42 1498 1679 78 0 4599 6074 13422 45% 3 17 20 4 TOTAL 1518 285 45332 40649 3006 597 109875 327831 377354 87% 7896 25 1

Annual Report 2003 - 04 205 Table 140:Rift Valley Province Hospital Administriatve Statistics 2004 HOSPITAL BEDS COTS ADM DISCH DEATHS ABSC W/PEOPLE OBD ABD % OCC ALOS AV. OCC. TOB TOI NAKURU PGH 541 46 23982 20145 1894 0 35339 166615 178448 93% 8 284 38 1 KERICHO DH 196 12 4414 3656 417 0 0 54906 63232 87% 13 264 20 2 MOSORIOT RHTC 15 2 1046 1036 5 0 0 2036 6205 33% 2 120 61 4 LODWAR DH 131 0 4412 3798 282 139 37594 55449 47815 116% 13 423 32 -2 KAKUMA 69 0 1030 831 60 0 4793 10301 14835 69% 12 149 13 5 MTRH 459 21 19449 17752 1477 72 37368 140543 155280 91% 7 293 40 1 NAROK 115 17 4895 3970 256 92 11343 30229 50518 60% 7 229 33 5 KAPSABET DH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NAIVASHA 112 54 6366 5974 467 134 7239 23986 35690 67% 4 144 40 2 ITEN 0 0 0 0 0 0 0 0 0 0 0 0 0 0 KAPEGURIA 155 4 6778 6309 291 83 0 26577 41750 64% 4 167 42 2 ORTUM MISSION 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NANDI HILLS DH 89 5 7117 6693 377 85 20447 28213 34310 82% 4 300 76 1 KAPTUMO H/C 9 2 0 21 0 0 27 20 671 3% 1 0 2 31 KITALE DH 182 0 18043 15698 1001 1625 30453 83596 66612 125% 5 228 101 -1 MOLO SDH 75 0 3067 2765 159 135 1786 12815 16125 79% 4 171 41 1 GILGIL HOSP 239 7 1633 1539 54 38 1556 42853 74784 57% 26 174 7 20 ELBERGON 36 0 1641 1307 76 3 0 8918 13140 68% 6 248 39 3 KAJIADO DH 122 0 3273 3059 204 13 6795 32914 44530 74% 10 90 27 4 LOITOKTOK 163 0 1488 1327 89 0 6328 22211 29992 74% 16 136 9 5 MAGADI 0 0 0 0 0 0 0 0 0 0 0 0 0 0 KILGORIS 0 0 0 0 0 0 0 0 0 0 0 0 0 0 LODIANI 0 0 0 0 0 0 0 0 0 0 0 0 0 0 LOGISA 81 0 2953 2639 79 0 0 11367 22113 51% 4 140 34 4 SIGOR 31 0 91 83 3 0 239 246 1922 13% 3 8 3 19 KAPKATET 147 9 576 526 10 2 0 2448 4836 51% 5 7 3 4 NANYUKI DH 80 5 625 616 22 16 1042 3529 2635 134% 5 42 8 -1 WAMBA CATHOLIC 178 16 1540 1304 167 0 1392 45381 70810 64% 31 234 8 17 MARARAL DH 63 0 1374 1166 154 17 33 9059 15309 59% 7 144 21 5 UASIN GISHU 0 0 0 0 0 0 0 0 0 0 0 0 0 0 KAPSOWAR MISSION 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MARAKWET DH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TAMBACH 59 6 1148 1050 22 9 0 6579 22885 29% 6 101 17 15 ELDAMARAVINE 78 4 1721 1534 61 13 0 29021 15017 193% 18 354 20 -9 BARINGO 145 1 396 2951 16 0 0 3429 4526 76% 1 23 20 0 LOKITAUNG 25 0 178 155 10 0 3 440 6050 7% 3 18 7 34 LOKORI 28 0 249 230 6 0 15 662 7644 9% 3 24 8 30

LOKICHAR H/C 19 0 52 43 2 0 89 204 997 20% 5 11 2 18 LORUGUM H/C 12 0 131 109 8 0 0 659 3276 20% 6 55 10 22 NAKWAMORU H/C 40 0 899 982 35 0 6355 12478 9740 128% 12 312 25 -3 KATILU H/C 9 0 150 137 3 0 87 373 1899 20% 3 41 16 11 KALOKOL H/C 19 0 30 30 0 0 0 130 2196 6% 4 7 2 69 TOTAL 3722 211 120747 109435 7707 2476 210323 868187 1065792 81% 7 221 30 1.7

Annual Report 2003 - 04 206 Although dispensaries and health centres are the entry point for the population into the health system, most of the facilities were noted to be dilapidated and need urgent rehabilitation to bring them into good usable operational status. There is need for the Ministry to review its rehabilitation policy.

Facility Utilization and Services Provided On utilization, it is generally considered that the quality and reliability of service utilization data is of great importance as staffing levels in many instances are based on utilization data. In the Human Resource Mapping study data collected especially in occupancy rates, number of outpatients, number of admissions and number of beds showed discrepancies. Overall, utilization statistics was collected from administrative records kept at the facilities. In terms of bed occupancy rate, the formula used by Health Management Information System of the Ministry is applicable and is as follows:

Occupancy Rate = Occupied Bed Days X 100 Available Bed Days

Where;

Total patients remaining each day added Occupied Bed = together for the days in the period Days Available Bed = Available Beds X Days in the period Days

The statistics showed that there was variation in occupancy rates with some districts having very low rates against the general trend normally observed at the facilities. Those with over 100% occupancy rates include Maragua District Hospital (102%) in Central Province, Kinango District Hospital (128%) and Malindi District Hospital (110%) in Coast; Isiolo District Hospital (200%), Mbeere District Hospital (187%), Mwingi District Hospital (120%) and Kitui District Hospital (108%) all in Eastern Province. In Nairobi, Mathare Hospital has occupancy rate of 110% while in North Eastern Wajir District Hospital has 130% occupancy rate.

In Nyanza Province, Gucha District Hospital (128%), Kisii District Hospital 166%, Kisumu District Hospital (158%) and Rachuonyo District Hospital (130%) are the facilities with high occupancy rates. In Rift Valley, Laikipia District Hospital (132%) and Turkana District Hospital (130%) are the only facilities with high occupancy rates.

In Western Province, Bungoma District hospital (110%), Butere/Mumias (111%) and Teso District Hospital (120%) are overcrowded.

Table 141: Facility Utilization for Provincial and District Hospitals

Region/Facility Outpatients Admissions Actual Beds Occupancy Rate

Central P.G. H (Nyeri) 140,966 25,203 396 108 Kiambu District Hospital 119,800 9002 356 64.8 Kerugoya District Hospital 86,610 14,292 208 120 Maragua District Hospital 56,495 2,270 20 102 Murang’a District Hospital 54,167 9,666 192 74 Nyahururu District 64,385 8,277 98 110 Hospital Thika District Hospital 193,575 24,111 265 154 Coast P.G.H Coast 53,736 29,256 359 200 Kilifi District Hospital 55,008 7,584 115 112 Kinango Hospital 20,835 1,559 69 129 Msambweni District 54,186 5,504 167 100 Hospital Lamu District Hospital 8,962 1,848 80 56 Malindi District Hospital 161,739 8,522 200 110 Wesu District Hospital 16,030 1,928 65 317 SUPPORT SERVICES ______

Region/Facility Outpatients Admissions Actual Beds Occupancy Rate Hola District Hospital 9,500 3,246 89 61 Eastern P.G.H Embu 162,649 18,705 533 93 Kitui District Hospital 107,403 10,892 182 108 Machakos Dsitrict 72,164 19,701 528 73 Hospital Makueni District Hospital 52,972 4,120 182 79 Marsabit District Hospital 21076 1791 80 79 Ishiara District Hospital 20521 3748 68 107 Mbeere District Hospital 28302 2304 25 150 Meru District Hospital 444124 11964 396 95 Nyambene District 29212 3941 40 151 Hospital Chuka District Hospital 68094 9107 109 187 Moyale District Hospital 45555 2034 83 47 Mwingi District Hospital 34173 4890 80 120 Nairobi Mbagathi District Hospital 130992 4271 165 71 North Eastern P.G.H.(Garrisa) 198246 6412 153 83 Ijara District Hospital 21600 400 17 200 Mandera District Hospital 52368 1506 147 74 Wajir District Hospital 220,00 3,650 190 130 Nyanza P.G.H (New Nyanza) 124,822 19,963 397 100 Bondo District Hospital 17,419 4531 48 62 Gucha District Hospital 29,136 8,199 44 128 Homa-Bay District 52,739 75,497 234 80 Hospital Kisii District Hospital 114,262 31,342 347 166 Kisumu District Hospital 97,161 14,370 189 158 Kehancha District Hospital 81,655 3,323 25 96 Isebania District Hospital 36,940 2,077 26 100 Migori District Hospital 33,885 4,474 64 85 Nyamira District Hospital 63,304 10,376 202 65 Nyando District Hospital 16,027 1,597 12 82 Rachuonyo District 21,588 2,244 47 130 Hospital Siaya District Hospital 66,000 9,051 164 84 Suba District Hospital 7,558 1,825 37 14 Rift Valley P.G.H Nakuru 139,891 29,011 453 80 Kabarnet District Hospital 14,787 5,632 143 66 Longisa District Hospital 13,803 4,030 154 60 Kapkatet District Hospital 42,626 11,980 147 66 Kajiado District Hospital 15,271 2,939 122 75 Loitoktok District Hospital 36,996 2,964 163 72 Kericho District Hospital 78,312 14,000 196 110 Iten District Hospital 19,751 3,500 74 45 Eldama Ravine District 53,230 3,500 72 54 Hospital Nanyuki District Hospital 52,105 5,828 80 132 Kapsabet District Hospital 47,491 10,747 158 70 Nandi Hills District 35,640 7,316 85 98 Hospital Narok District Hospital 23,109 4,488 122 96

Annual Report 2003 - 04 208 SUPPORT SERVICES ______

Region/Facility Outpatients Admissions Actual Beds Occupancy Rate Maralal District Hospital 40,862 2,084 130 80 Kitale District Hospital 239,669 21,020 182 133 Lodwar District Hospital 15,738 3,726 131 132 Western P.G.H Kakamega 89,380 18,274 359 80 Bungoma District Hospital 118,305 10,040 182 110 Busia District Hospital 21,477 8,020 173 72 Butere/Mumias District 26,291 4,643 26 111 Hospital Mt. Elgon District Hospital 9,8873 158 24 145 Teso District Hospital 65,398 6,000 24 120 Vihiga District Hospital 27,207 6,448 145 63

From all the data given on utilization and the data reviewed in published documents, there is need for the Ministry to improve on its data capture in all its facilities. The need for production of quality and timely data for policy and management decision should be made a priority.

The number of beds in health facilities has significant impact on the distribution of health personnel. Analysis of data on bed per population shows that Eastern Province is better placed with one bed for 1334 people or 75 beds for 100,000 people compared to Western Province with poor proportion of 1:1867 people and 53 beds per 100,000 people as shown in Table below. Nairobi’s case is extreme due to the exclusion of Kenyatta National Hospital from coverage. Although MOH facilities with many beds require a large staff and usually have priority in deployment, this has not been strictly followed because some facilities with large number of beds have comparatively few medics.

Table 142: Number of Beds by Province

Province Population Number of Beds Bed Per Bed per 100,000 Population people Central 18,538 2,666 1,470 68 Coast 60,649 1,792 1,596 63 Eastern 180139 3882 1334 75 Nairobi 656997 733 3625 27 North Eastern 35592 724 1707 58 Nyanza 4868010 3064 1589 63 Rift Valley 8077517 4741 1704 59 Western 3954081 2118 1867 53 Total 32751523 19720 1661 60

Annual Report 2003 - 04 209 SUPPORT SERVICES ______

14. HUMAN RESOURCE MAPPING Ministry of Health recognized that human resource planning for health by region, type of expertise, staff category, gender and skill is essential for health care delivery. In recognition of this, MOH is in the process of creating updated human resource data bank to facilitate policy decisions in matters of staff deployment, posting, and training and skill mix gaps.

This section of the report focuses on profile of health personnel covered during the mapping study. It highlights health manpower available in Ministry of Health facilities by giving information of their distribution by designation, skill mix, training needs and mobility, amongst others.

14.1 Staffing Level by Designation and Gender

The results showed that a total of 34,986 health employees of whom 19,353 (55.3%) are women and 15,633 (45.7%) men were mapped in their respective health facilities. By definition an employee was mapped if he was physically found at the facility by survey teams or if absent, the head of the facility confirmed to the survey team by countersigning their forms. The absent employees were classified as those who were on leave, on night shifts, attending training locally or overseas, on study/sick leave. Those whose forms could not be countersigned to be working at the facilities were excluded. Further those whose forms were brought to the headquarters for countersigning are excluded until verification is done by the Ministry. The distribution of staff by facility type is given in Table 4.1

Table 143: Workforce Profile by Gender and Facility Type

Facility Type Female Male Totals % Headquarter Department/Divisions 284 397 681 1.9 2,565 1,435 4,000 Provincial Hospitals 11.4 9,126 7,580 16,706 47.6 District Hospitals 3,175 2,448 5,623 16.1 Health Centres 2,514 2,451 4,965 14.2 Dispensaries Rural Health Training and 719 779 Demonstration Centres 1498 4.3 484 165 649 1.9 National & Specialized Hospitals

PMO and MOH 486 378 864 2.5 19,353 15,633 34,986 100.0 Total 100 Percentage (%) 55.3 45.7

Annual Report 2003 - 04 210 SUPPORT SERVICES ______

The data showed that members of the staff are concentrated in district hospitals accounting for 48.0% followed by health centres with 16.0% and dispensaries account for 14.0% while provincial hospitals account for 11.0% of the personnel. Further analysis of the staffing at the facility levels indicated that dispensaries are mostly/grossly understaffed by one person and in some cases support staff was in charge of the facilities as shown in Table below. Other findings show that at district and provincial hospitals, most of the work of staff are related to care of inpatients while the staff employed in health centres and dispensaries attend to outpatient curative and MCH/FP services.

Figure 54: Percentage Distribution of Workforce by Facility type

Provincial Others. 11% Hospitals . 11%

Dispensaries. 14%

Health Centres. 16% District Hospitals. 48%

Table 144 gives distribution of health personnel by designation and province. The statistics show that Rift Valley has the highest number with 8650 personnel followed by Eastern with 5918 personnel. However, in terms of a health worker per population, Central Province is better served with 1 health worker for 705 people while North Eastern Province is worst served with 1 health worker for 1646 people. Nationally, the ratio of health worker per population is 1:922.

Annual Report 2003 - 04 211 SUPPORT SERVICES ______

Table 144: Distribution of Employees by Designation and Province North Rift Central Coast Eastern Nairobi Eastern Nyanza Valley Western Total Doctors 143 114 170 233 19 101 220 80 1,080 Clinical Officers 275 215 330 118 76 280 640 214 2,148 Registered Nurses 594 386 569 257 93 413 814 295 3,421 Enrolled Nurses 2244 1071 2280 629 249 1494 3145 1482 12594 Public Health 634 337 656 220 113 495 1342 366 4163 Administration 240 144 304 245 22 329 388 125 1797 Accounts 0 1 1 48 0 0 3 0 53 Med Engineering 46 40 61 28 11 40 83 28 337 Technologist Diploma 250 192 266 183 43 209 476 165 1784 Lithographers 0 0 0 1 0 0 0 0 1 Nutrition 60 28 40 43 9 24 117 26 347 Orthopaedic 73 25 51 29 9 31 88 19 325 Personnel 2 2 0 40 1 1 4 2 52 Secretarial 29 22 34 97 1 12 27 13 235 Procurement 12 7 12 35 1 8 10 4 89 Social Welfare 1 0 2 10 0 2 5 4 24 Boilers 1 0 0 0 0 0 0 0 1 Building 29 8 18 36 0 14 19 12 136 Chemists 0 1 0 9 0 4 0 0 14 Dental Technology 61 36 53 61 5 27 84 23 350 Economist Planning 0 6 0 13 0 0 0 0 19 Finance Admin 0 0 0 0 1 0 0 0 1 Health Administration 2 2 5 4 0 2 5 3 23 Health Records Information 88 50 78 65 9 47 143 41 521 House Keeping 38 6 17 33 2 14 11 6 127 Inspectors 0 1 2 4 2 1 3 1 14 Librarians 0 0 1 4 0 0 0 0 5 Painting 0 0 0 7 0 0 0 1 8 Pham Technologist 45 37 69 128 19 37 96 29 460 Physiotherapist 120 82 124 61 10 79 143 63 682 Radiation Protection Board 47 28 49 32 9 43 74 22 304 Scientist Researchers 0 0 0 7 0 4 2 0 13

Annual Report 2003 - 04 212 SUPPORT SERVICES ______

Table 144: Distribution of Employees by Designation and Province North Rift Central Coast Eastern Nairobi Eastern Nyanza Valley Western Total Others 612 314 726 421 74 650 707 339 3843 Radiophycists I/II/III 1 0 0 13 0 0 1 0 15 Total 5647 3155 5918 3115 777 4361 8650 3363 34986

2,806, 5,180,1 2,656,9 1,235,5 4,868,0 8,077,51 3,954,08 32,697, Population 3,918,538 649 39 97 92 10 7 1 523 0.603 47222 0.63055 1.18472 0.80555 0.678472 0.815277 0.68194 Worker 0.53125 2 556 0.60625 222 556 22 78 444

Source: Human Resource Mapping 2004.

14.2 Skill mix in Health Facilities The general policy on skill mix is to see a shift in the manpower mix towards more skilled personnel as a means of service quality. Table 145 gives the data on the key health personnel mapped during the study.

Table 144: Distribution of Key Health Personnel by Designation and Gender

Designation Women Men Total % Doctors 275 805 1080 3.1 Clinical Officers 729 1419 2148 6.1 Registered Nurses 2371 1050 3421 9.8 Enrolled Nurses 9834 2758 12592 35.9 Public Health Officer 1152 3011 4162 11.9 Public Health Technician 1845 3199 5044 14.4 Others 3146 3391 6537 18.8 Total Health Personnel 19353 15633 34986 100.0

From the data it is evident that registered and enrolled nurses are the largest group as they constitute 45.7% of the Ministry’s workforce followed by public health technicians and public health officers at 14.4% and 11.9% respectively. Doctors and clinical officers together constitute only around 9.0%. The proportion of doctor to clinical officer is 1:2 while doctor to nurses is 1:15. This is a situation which the Ministry should rectify as a priority and put in place service production targets in particular for preventive service.

It was observed that because of shortage of these key personnel, the unskilled staff working beyond their normal level of competency performed many services such as medicine dispensing and X-ray. Detailed information on employee distribution by gender and designation is given in Table 4.4. The category where women are the majority are secretarial, nutrition, nursing and orthopaedic services. As for doctors, women only constitute 25.5% and this should be improved on by having more women doctor trainees at the universities. Similarly, women should enrol more to be trained as clinical and public health officers.

The Service Availability Mapping (SAM) 2004, on Human resources observed that there is a great discrepancy of staffing and more personnel are concentrated in the capital city than outside the capital city.

Doctor Density per Observations Mean Std. Minimum Maximum 100,000 population Deviation Capital City 1 28.54589 28.54589 28.54589 Out side capital city 70 3.204919 2.630444 0 15.12229

Annual Report 2003 - 04 213 SUPPORT SERVICES ______

Entire country (Kenya) 71 3.561834 3.983085 0 28.54589 v 29 doctors per 100,000 populations serving in the capital city. v 4 – 15 doctors per 100,000 people serving outside the capital city. v Minimum number of doctors outside the capital city zero (0) and a Maximum of 15 while capital city minimum of 29. Clinical officer Density Observations Mean Std. Minimum Maximum per 100,000 population Deviation Capital City 1 5.510789 5.510789 5.510789 Out side capital city 70 8.709201 4.41584 1.818182 24.25404 Entire country (Kenya) 71 8.664153 4.400586 1.818182 24.25404

v Average number of clinical officers serving 100,000 people in the capital city is 6. v Average number of clinical officers serving 100,000 people out side capital city is 9. v The minimum number of clinical officers serving 100,000 people outside capital city is 2 and maximum is 24 while in the capital city is 6.

Nurse Density per 100,000 Observations Mean Std. Minimum Maximum population Deviation Capital City 1 132.1855 132.1855 132.1855 Out side capital city 67 60.07785 34.16911 9.059745 148.9713 Entire country (Kenya) 68 61.13825 35.02236 9.059745 148.9713

v Average Nurse Density per 100,000 people in the capital city is 132. v Average nurse density is 60 per 100,000 people in outside capital city. v Minimum is 9 and maximum is 149 per 100,000 population. v Ratio of nurses to one doctor is on average 26 per doctor with a minimum of 2 and maximum of 108 per one doctor. v The ratio of nurses to if relevant, doctor and clinical officer is on average 4 with minimum of 1 and maximum of 22 per one doctor and clinical officer.

Annual Report 2003 - 04 214 SUPPORT SERVICES ______

Ratio of Nurses to Doctors and Relevant to Doctors or Clinical officers Ratio of Nurses and Observations Mean Std. Minimum Maximum Midwives to Deviation Doctors 68 25.96235 19.28407 1.9375 107.5 If relevant, Doctors and 70 4.187427 3.91526 0.1930502 22 Clinical Officers

All Human Resource in Observations Mean Std. Minimum Maximum Health (HRH) Density per Deviation 100,000 population Capital City 1 166.2422 166.2422 166.2422 Out side capital city 70 69.4172 40.02753 9.293063 172.058 Entire country –(Kenya) 71 70.78093 41.36856 9.293063 172.058 v Average all HRH density is 166 in capital city per 100,000 people. v Average all HRH density out side the capital city is 69 with a minimum of 9 and maximum of 172 per 100,000 people.

Table 145: Employee Distribution by Designation and Gender

Designation Women Men Total % Women

275 805 1080 25.5 Doctors Clinical Officers 729 1419 2148 35.5 Registered Nurses 2371 1050 3421 69.3 Enrolled Nurses 9834 2758 12592 78.1 Public Health Officers 1151 3011 4162 27.6 Administration 752 1045 1797 41.8 Accounts 11 42 53 20.7 Health Administration 2 21 23 8.7 Orthopedic 169 156 325 52.0 Nutritionist 279 68 347 80.4 Technologist Diploma 640 1145 1785 35.8 Lithographers 0 1 1 0 Med Engineering 61 276 337 18.1 Secretarial 229 6 235 97.4 Social Welfare 12 12 24 50 Radiation Protection 77 227 304 25.3 Board Personnel 14 38 52 26.9 Building 45 91 136 33.1 House Keeping 90 37 127 70.9 Boilers 0 1 1 0 Inspectors 1 13 14 7.1 Librarians 2 3 5 40 Painting 1 7 8 14.2 Physiotherapist 204 478 682 29.9 Health Record 180 341 521 34.5 Information Pham Technologist 145 315 460 31.5

Annual Report 2003 - 04 215 SUPPORT SERVICES ______

Procurement 16 73 89 18.0 Radiophycists I/II/III 0 15 15 0 Scientist Researchers 4 9 13 30.8 Others 1929 1914 3843 50.2 19353 15633 34986 55.3 Total

Source: Human Resource Mapping 2004.

Annual Report 2003 - 04 216 SUPPORT SERVICES ______

14.3 Distribution of Key Health Personnel by Province

Analysis of key health personnel by province is given in Table 146. Nairobi with 233 doctors has 9 doctors per 100,000 population while North Eastern is the worst hit by unequal distribution with only 1 doctor per 100,000 people. The remaining provinces have 2 to 5 doctors per 100,000 people. In terms of nurses, Central Province with 72 nurses per 100,000 people is well placed followed by Eastern Province with 55 nurses per 100,000 people. As for clinical officers the ratio is almost uniform averaging at 6 per 100,000 people. North Eastern Province is the most disadvantaged with only 27 nurses for 100,000 people while Nairobi has 33 nurses per 100,000 people.

Detailed data for facility profiles given in Volume II of annexes show that some facilities are overstaffed with nurses while in other facilities there is gross understaffing. The Ministry should undertake detailed comparison analysis of staffing levels and workload from the results of this study. This will assist in the staff redeployment as appropriate to meet service needs.

Table 146: Distribution of Key Health Personnel by Province

Population Doctors Clinical Officers Nurses Per Province D/P CO/P Per N/P Per 100,000 No. 100,000 No. No. Ratio Ratio 100,000 Ratio people people Nairobi 2,656,997 233 11403 9 118 22517 4 886 2859 33 Central 3,918,538 143 27402 4 275 14249 7 2,838 1404 72 Nyanza 4,868,010 101 48198 2 280 17385 6 1,907 2515 39

North 1,235,592 19 65031 1 76 16257 6 342 3741 27 Eastern

Rift 8,077,517 220 36715 3 640 12621 8 3,959 2003 49 Valley

Eastern 5,180,139 170 30471 3 330 15697 6 2,849 1760 55 Western 3,954,081 80 49426 2 214 18477 5 1,777 2225 45 Coast 2,860,649 143 20004 5 215 13305 7 1,457 1963 51

Total 32,751,523 1,080 30325 3 2,148 15247 6 16015 2045 49

D/P – Doctor Population Ratio CO/P – Clinical Officer Population Ratio N/P – Nurse Population Ratio

In terms of health personnel population ratios, North Eastern Province with doctor population ratio of 1:65031 and nurses population ratio of 1:3741 is worst served followed by Western with doctor population ratio of 1:49,426 and Nyanza province with the ratio of 1:48,198. Nairobi despite the fact that Kenyatta National Hospital is not included is better served with doctor population ratio of 1:11403

Annual Report 2003 - 04 217 SUPPORT SERVICES ______

14.4 Staffing Norms It is generally accepted that absolute norms and standards for a hospital service utilization and capacity do not exist and that standards and norms are usually arrived at by balancing the possible with the feasible and desirable and are therefore relative. Further analyses based on norms depend heavily on having good data about catchment population, attendance rates and other key statistics. For example, staffing of medical specialist is based on the size of the population served by the hospital, facility based statistics, the need of teaching both within the facility and at district hospitals and demand for research.

Analysis of staffing levels at facilities show wide variations. At dispensary level, most of the facilities are run by one community nurse and in some cases by a support staff as shown in table 4.6. This does not conform to the MOH norms given in the “Definition and Categorization of Health Facilities in Kenya.” In terms of key health personnel, a dispensary offering basic curative outpatient services, MCH/FP services, environmental health services and immunization services with catchment population of 15,000 people, should have three to five enrolled community nurses and one public health technician as indicated in table 4.6. From these results, it is evident that about 2.8% of the dispensaries are managed by support staff and 47.3% by one community nurse. In total, 50% of the dispensaries are grossly understaffed and cannot perform their roles effectively. In terms of provincial distribution, Coast Province has the highest proportion of 68% of the dispensaries with one nurse followed by North Eastern with 65%. Central Province has the lowest proportion of 19%.

Table 147: Distribution of Dispensaries Understaffed by Staff Category

Province Staff category Manning Recommended MOH Facility Staffing Norm

Support One Nurse and Support staff only Staff

No % Provincial Distribution Nairobi - 1 - Three enrolled community Central 6 38 19.0 nurse, One public health Coast 4 98 68.0 technician, one laboratory Nyanza 3 95 52.8 technician, two support staff Western - 13 16.0 and one watchman Eastern 8 179 55.1 North Eastern 5 28 65.1 Rift Valley 16 270 50.0 Total 42(2.8%) 722 47.3

Similarly, for health centres the study found that there were, on average, three community nurses and this does not match the standard staffing norm of a health centre which requires one clinical officer, four enrolled community nurses, and one public health technician among others. The district hospitals were found to be lacking specialists in key areas such as dentist, cardiologist, gynaecologists, surgeons, etc. The guidelines for Ministry of Health staffing norms are given in Annex II. Overall, this study has given details of staffing levels by facilities in Volume II Annexes. The Ministry should use the result in making changes in deployment of key health personnel and training requirements

Annual Report 2003 - 04 218 SUPPORT SERVICES ______

14.5 Distribution of Key Personnel by Age

The data given in Table 149 show that 69.9% of the staff are in age group 25 to 44 years while 10 doctors and 13 enrolled nurses have attained the age of retirement. In totality, there are 56 health personnel who are 55 years of age. This data is critical for the Ministry for the production of projected retirement plans. Further, the data can be used to project future recruitment policy for key personnel.

Table 148: Distribution of Key Health Personnel by Age-Group

Staff Category AGE GROUP Below 25 25-34 35-44 45-55 Above 55 No % No % No % No % No % Doctors 9 0.8 674 62.4 252 23.3 135 12.5 10 1.0 Clinical 21 1.0 1,220 56.8 558 26.0 349 16.2 - - Officers Registered 47 1.4 1,358 39.7 1095 32.0 921 26.9 - - Nurses Enrolled Nurses 55 0.4 2,778 22.0 5,140 40.8 4,608 36.6 13 0.2 Total 132 0.7 6,030 31.3 7,045 36.6 6,013 31.2 23 0.2

14.6 Academic Qualification and Training

In the health sector, a contributory factor to the manpower shortage is the imbalance that has developed between the expansion of health services infrastructure and the limited capacity of the training system for health personnel. The statistics given in Table 150 show that 75.5% of MOH personnel are of certificate and diploma levels while only 5.9% are graduates or post-graduates. Similarly the same trend is reflected in the staffing of facilities as the majority of the staff are certificate and diploma levels. There is therefore the need to have an education programme which is responsive to the needs of the health sector in general, and for serving staff.

Table 149: Distribution of Employees by Academic Qualifications

Primary O- A- Higher University Post Facility and Certificates Diploma Doctorate Total Level Level Diploma Graduates Graduate Other 18 Dispensaries 496 44 3442 472 61 19 - 5 4965

District 1410 1661 89 7294 4329 1105 543 258 17 16706 Hospitals 18 HQ/DEPT/DIV 93 216 80 70 45 82 73 4 681

Health Centres 490 472 25 3147 1289 124 42 30 4 5623 National and Specialized 90 100 3 263 117 22 35 18 1 649 Hospitals 4 PMO/MOH 35 71 224 161 83 233 52 1 864

Provincial 27 279 386 1699 925 247 997 143 9 4000 Hospital

Annual Report 2003 - 04 219 SUPPORT SERVICES ______

Primary O- A- Higher University Post Facility and Certificates Diploma Doctorate Total Level Level Diploma Graduates Graduate Other Rural Health Training and 191 210 20 479 284 128 131 49 6 1498 Demonstration Centres 204 Total 3084 3560 16628 7647 1815 1382 624 42 34986

% Total 8.8 10.2 0.6 47.5 21.8 5.2 4.0 1.8 0.1 100

From the statistics, it is clear that in terms of capacity building there is need for training as most of those who manage health facilities require both higher academic qualification and management training. In addition, in the last 3 years it was found that most of key health personnel had not attended any training as shown in table 151.

Those who indicated that they had attended training mainly referred to workshops and seminars. It was not possible to assess the quality or relevance of the workshops and seminars in this study. Overall, since the response from employees on training was poor, there is need to undertake training needs assessment. The key issue is for the Ministry to address how MOH personnel can be equipped with modern management technique in running health institutions. It was further observed through discussions with employees that lack of training has made some of them to stagnate in one job for many years. Since training is regarded as a tool and investment to further develop staff to further their skills, to motivate them and to be refreshed, there is need for the Ministry to design a national training programme for serving staff.

Table 150: Employee Distribution of Last Training Date

Facility 12 Months 24 Months 36 Months None Total

Provincial 202 99 131 3568 4000 Hospital District 1169 539 656 14342 16706 Hospital Health Centres 377 170 189 4887 5623 Dispensaries 289 123 137 4416 4965

HQ Depts. 78 28 49 526 681

National and 45 22 25 557 649 Specialized PMO/MOH 161 56 53 594 861

Rural Health 129 69 91 1209 1498 Training and Demonstration Centre Total 2450 1106 1331 30099 34986

% Total 7.0 3.2 3.8 86.0 100

Source: Human Resource Mapping 2004.

Annual Report 2003 - 04 220 SUPPORT SERVICES ______

Annual Report 2003 - 04 221