USAID KENYA Aphiaplus WESTERN KENYA

USAID KENYA APHIAplus WESTERN KENYA

YEAR 9 EXTENSION (MARCH – NOVEMBER 2019)

YEAR 9 Q2 REPORT

EMR SCALE UP-KAKAMEGA, BUSIA AND VIHIGA COUNTIES

Updated June 2019

This publication was produced for review by the US Agency for International Development. It was prepared by staff of PATH’s country program in Kenya.

USAID KENYA (APHIAplus WESTERN KENYA) PROGRESS REPORT FOR Q3 FY 2017 USAID KENYA APHIAplus WESTERN KENYA

YEAR 9 EXTENSION (MARCH – NOVEMBER 2019)

Award No: AID-623-A-11-00002

Prepared for Dr. Maurice Maina US Agency for International Development Kenya c/o American Embassy United Nations Avenue, Gigiri PO Box 629, Village Market Nairobi 00621 Kenya

Prepared by PATH’s Country Office in Kenya ACS Plaza, 4th Floor Lenana and Galana Road PO Box 76634 Nairobi 00100 Kenya

DISCLAIMER The authors’ views expressed in this report do not necessarily reflect the views of the US Agency for International Development or the US Government.

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT ii

Table of contents

Executive Summary ...... v 1. Introduction ...... 1 2. Methodology ...... 1 3. Findings of Rapid Assessment ...... 2 3.1 Distribution of assessed sites ...... 2 3.2 Existence of EMR system ...... 2 3.3 Management support for EMR system ...... 3 3.4 EMR Enabling Infrastructure ...... 3 3.4.1 Availability of space and physical security for EMR ...... 3 3.4.2 Accessibility to power/electricity ...... 5 3.4.3 Availability of equipment (computers) ...... 7 3.4.4 Accessibility to voice and data communication facilities...... 8 3.5 Staffing and training in EMR ...... 10 3.6 Data concordance ...... 11 4. Conclusion ...... 11 5. Report validation and County Engagement ...... 12 6. Minimum Requirements for EMR ...... 12 7. Gap analysis ...... 14 8. Cost of EMR deployment ...... 15 Annexes ...... 17 Annex 1 List of sites by total cost of EMR deployment ...... 17

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT iii

Abbreviations

CCC Comprehensive Care Centre

DHIS District Health Information System

EMR Electronic Medical Records

ICT Information Communication Technology

LAN Local Area Network

MCH Maternal and Child Health

NASCOP National AIDS and STI Control Program

OPD Outpatient Department

PoE Power of Ethernet

SDPs Service Delivery Points

TB Tuberculosis

UPS Uninterruptible Power Supply

VPN Virtual Private Network

WAN Wide Area Network

WAP Wireless Application Protocol

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT iv

Executive Summary

Distribution of assessed sites: Kakamega County had the majority (45) of the sites followed by Vihiga (17) and then Busia (8). Half of the sites were health centres followed by sub county hospitals and dispensaries. There was only one regional referral hospital (Kakamega County General Hospital) and one County referral hospital, Vihiga County Referral hospital.

Existence of EMR system: Only 5 of the 70 assessed facilities had a dedicated TB clinic and only 1 (of the 5) had an EMR which was functional. Similarly, 67 facilities had a dedicated MCH service delivery point and out of these 40 had an EMR but only 20 (50%) were functional. All the sites had a CCC and 56 of these had an EMR but only 35 (63%) were functional.

Availability of server room: 71% of the sites had a server room including the Kakamega regional referral and Vihiga county referral hospitals. And only 74% and 80% of the sub county hospitals and health centres had server rooms, respectively.

Physical security at patient encounter points: Only 28 (40%) of the sites had lockable cabinets that are of particular interest because the proposed EMR scale up to other service delivery points would be using tablets that would require lockable cabinets for their security. However, most (over 90%) had lockable doors and bars on the windows. The physical security at most CCCs was adequate.

Reliability of power/electricity: Only 30% of the sites did not experience power blackouts/outages during the month of February. All the two referral sites (Kakamega and Vihiga) did not experience any power problem, however other facilities did experience blackouts/outages; 79% of the sub county hospitals blackouts as were 71% and 61% of the health centres and dispensaries, respectively. In summary, the power situation in most of the sites is unreliable.

Availability of source of power backup: Overall, 16% of the sites did not have any source of power backup at all. A small proportion, 8.6% had UPS for power backup while the bigger facilities reportedly used generators for power backup including 63% of the sub county hospitals. The smaller facilities, health centres had a preference of solar power as a backup with a quarter reportedly used solar as was 36% of the dispensaries.

Availability of voltage stabilizers: Voltage stabilizers are necessary for the protection of EMR equipment more so in an environment where power outage and fluctuations are common like in the assessed sites. Even though the two referral facilities all had voltage stabilizers, overall they were not common as only 21% of the sites had this vital component.

Availability of computers: Overall, 93% of the assessed sites had at least a computer for HIS related activities. All the hospitals had at least a computer while 94% and 79% of the health centers and dispensaries had at least a computer, respectively. About two thirds (140) of the computers were in CCCs followed by the pharmacy that had 40 computers.

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT v

Accessibility to voice and data communication facilities: Only 44% of the sites had and used an official cellphone for voice communication. The two referral sites had official cellphone, 63% of the sub county hospitals also had and a smaller proportion (37%) of the health centres.

Availability of wide area network (WAN): Most (89%) of the sites had some type of facility for wide area network (WAN). The commonest was the personal cellphone modem which unfortunately may not be sustainable. Only a fifth (21%) of the sites had official cellphone modems and these were mainly sub county hospitals and health centres.

Availability of local area network (LAN): Seventy nine percent of the CCC had LANS and so were 67% of the TB clinics and MCHs, respectively. Less than 30% of the other departments (laboratory, pharmacy and outpatient) had LANS.

Staffing and training in EMR: Overall, only 30% (of the 1155) had been trained with Vihiga county referral hospital having 48% of their staff trained. Proportions of trained staff for the other facility type were below 35%, with the dispensaries at 21%.

Data concordance: Data concordance in most of sites was good across board. Overall 92% of the assessed sites had completely filled MOH data capture forms. Generally, data concordance was good across site types. Minimum requirements, gap analysis and cost of deployment

Minimum Requirements for EMR: The minimum cost requirements for setting up an EMR by site type is as follows; Regional referral hospital $40,727, County referral hospital $37,580, Sub County hospital $34,042, health centres $29,815 and dispensary $25,414.

Availability of EMR system: Fifty seven (81%) of Sites had and EMR system that was running on the KenyaEMR platform, 37 (53%) of which were exclusively on KenyaEMR. Twenty (29%) sites had a combination of KenyaEMR and others like WebADT, CHIS and Funsoft. However, there was one Site that was on Smartcare.

Availability of selected EMR equipment: Only one Site had a router, 56 (80%) had a switch but not PoE (power of Ethernet), and none had WAP. Further, no Site had a 9U cabinet though several sites had a 4U cabinet of which were fully utilized. Fifty seven (81%) of the Sites had servers of various capacities though majority were HP. A local area network (LAN) was present in 56 (80%) of the Sites; and slightly over half (51%) of the sites did not have a power back, however 16 and 17 sites had a generator and solar, respectively.

Cost of EMR deployment: The total cost of EMR deployment in the 70 Sites is $2,243,361 with the 39 health centres taking about half of this amount ($1,190,796). The 9 dispensaries will need a total $237,849.

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT vi

1. Introduction

PATH carried out a rapid assessment of ICT infrastructure requirements for scale up of EMR in key service delivery points including CCC, OPD, TB clinic, MCH clinic, laboratory, pharmacy and inpatient. It was carried out in 70 health facilities in Kakamega, Vihiga and Busia counties in March- April 2019. During the January-February 2019 period, the project carried out an administrative closure, having ended activity implementation on 31st December 2018. It received a no cost extension to carry out the EMR scale up activity in March- November 2019. The EMR scale up activity was informed by the recently concluded national data quality audit in October-November 2018 which revealed that health facilities with point of care Electronic Medical Records (EMR) and reporting using EMR had better data concordance and accuracy than those using only paper based or hybrid systems of both paper and EMR retrospective data entry platforms.

The project has previously supported deployment of EMR at supported facilities in collaboration with I-TECH and more recently Palladium consortia. This however only targeted the comprehensive care clinics and even then, there was limited use of EMR systems for reporting. Currently, 63 out of the 231 project supported health facilities have an EMR system in place. However only 59 are operational and are located in the CCCs only.

Some of the challenges faced by health facilities using EMR systems, include frequent power outages in the region that hamper use of the power dependent computer desktops provided for point of care use; break down of critical equipment such as uninterrupted power supply (UPS) units and N- computing devices; delayed or non-replacement of broken down equipment;, and inadequate capacity by health staff to use EMR systems optimally.

The project proposes to mitigate some of these challenges through use of tablets at the service delivery points rather than desktops since these devices are powered overnight, and can then be used through the day at the point of care without any outage. These tablets will connect, through a secure Virtual Private Network (VPN) to a facility database, the central county database located at the County Health Records Information Officer’s office and the national data warehouse.

The tablets will have a SIM card, which connects to the servers via mobile data network (Safaricom, Airtel or Telkom depending on the facility’s best network coverage). The tablets will be configured to only access the VPN tunnel for optimal use and minimize unauthorized use. To minimize loss and/or theft, the project will provide very visible and non-erasable branding on the tablets, develop strict user agreements that facility in-charges sign-off on and facilities to provide lockable cabinets where the tablets will be safely stored when not in use.

The project in this scale-up phase carried out a rapid Information Communication Technology (ICT) assessment to identify ICT equipment needs, procure identified equipment, deploy at targeted facilities, support facility capacity building and on-going supportive supervision to ensure EMR point of care use and reporting to DHIS2. This was done collaboratively with Kenya Health Management Information systems (KenyaHMIS) and Health IT projects working closely with AMPATHplus, Tupime Kaunti project and county and sub-county health management teams. 2. Methodology

The assessment was conducted in 70 sites that had current ART client numbers of more than 190 by December 2018. These were broken down by county as follows; Kakamega 45, Vihiga 17 and Busia 8.

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 1

Fourteen Assessors, most of them familiar with EMR, were recruited and trained for two days before embarking on data collection. The Assessors were organized into 7 teams of two individuals each to cover a site per day. Data collection took 10 days using an adapted tool of the “HIV Care EMR Readiness Assessment checklist”.

The assessment focused on two aspects; a rapid assessment to establish the status of EMR readiness domains and a gap analysis to document gaps in equipment, staffing and training.

Data entry was done in Kakamega project office by one Data Entrant using Excel. Data analysis was done using SPSS. The analysis focused on establishing the status of key EMR readiness domains that included presence of EMRs, power supply based on frequency and duration of outages, presence and location of a server, equipment, space, security, involvement of facility management in planning for EMR and presence of EMR champions. A gap analysis focused on documenting the EMR needs and their cost at site level leading to a total cost of deployment in all the 70 sites. 3. Findings of Rapid Assessment 3.1 Distribution of assessed sites

Table 1 provides a summary of the distribution of assessed sites by type of facility and county. Kakamega County had the majority (45) of the sites followed by Vihiga (17) and then Busia (8). On type of facility, half of the sites were health centres followed by sub county hospitals and dispensaries. There was only one regional referral hospital (Kakamega PGH) and one County referral hospital, Vihiga County referral hospital.

Table 1 Distribution of facilities by type and county Type of site Busia Kakamega Vihiga Total Regional Referral Hospital 0 1 0 1 County Referral Hospital 0 0 1 1 Sub County hospital 3 12 4 19 Health Centre 4 20 11 35 Dispensary 1 12 1 14 Total 8 45 17 70

3.2 Existence of EMR system

Table 2 provides a distribution of EMRs within the service delivery points. As shown, only 5 of the 70 assessed facilities had a dedicated TB clinic and only 1 (of the 5) had an EMR which was functional. Similarly, 67 facilities had a dedicated MCH service delivery point and out of these 40 had an EMR but only 20 (50%) were functional. Of interest were the comprehensive care centres (CCC), a forerunner in EMR installation; all the facilities had a CCC and 56 of these had an EMR but only 35 (63%) were functional. The situation in the rest of the departments is as shown. In summary, only 137 (39%) of the SDPs in the 70 sites had an EMR, however of these only 69% were functional.

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 2

Table 2 Distribution of sites by presence of an EMR system and functionality (as at March 2019) by site type Service No. of sites with EMR in the Sites with EMR in the Sites with Delivery Point a dedicated SDP SDP functional SDP (%) functional EMR EMR (%) TB Clinic 5 1 1 20% 100% MCH 67 40 20 60% 50% CCC 70 56 35 80% 63% OPD 70 9 9 13% 100% Laboratory 68 9 9 13% 100% Pharmacy 70 22 20 31% 91%

3.3 Management support for EMR system

Management support is fundamental in implementing a successful electronic medical records (EMR) system. This includes facility management involvement in planning for EMR and also having an in- house champion for EMR. Overall, most of the sites had strong management support for EMR.

3.4 EMR Enabling Infrastructure

To assess EMR enabling infrastructure, the assessors focused on existence of separate data rooms and adequacy of space to accommodate an EMR facility, electrical power capacity at the sites, availability of voice and data communication systems, and availability and type of wide and local area networks (WAN and LAN). 3.4.1 Availability of space and physical security for EMR

The assess availability of space and physical security the assessment focused on availability of a server room and existence of selected security modalities such as availability of lockable cabinets and doors, grills on doors and bars on windows, and presence of a security guard among others.

Availability of server room

Figure 1 presents a distribution of sites with a server room. As shown, 71% of the sites had a server room including the Kakamega regional referral and Vihiga county referral hospitals. And only 74% and 80% of the sub county hospitals and health centres had server rooms, respectively.

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 3

Figure 1 % distribution of sites with server room by site type 120

100 100 100

80 74 80 71

60 % 43 40

0 Regional County referral Subcounty Health centre Dispensary Overall referral hospital hospital hospital

Physical security at patient encounter points

Table 3 provides a summary of the physical security of the sites based on selected security items such as having grills on doors. As shown, only 28 (40%) of the sites had lockable cabinets that are of particular interest because the proposed EMR scale up to other service delivery points would be using tablets that would require lockable cabinets for their security. However, most (over 90%) had lockable doors and bars on the windows. Though not clearly depicted on the table, the assessment established that the physical security at most CCCs was adequate.

Table 3 Distribution of Sites with physical security by type of site

Type of site Regional County Sub county Health Dispensary Type of security item Total Referral Referral hospital Centre Hospital Hospital n 1 1 9 11 8 28 Lockable cabinets % 100.0% 100.0% 47.4% 31.4% 57.1% 40.0% n 1 1 15 20 8 44 Grills on doors % 100.0% 100.0% 78.9% 57.1% 57.1% 62.9% n 1 1 18 33 12 64 Bars on windows % 100.0% 100.0% 94.7% 94.3% 85.7% 91.4% n 1 1 18 33 14 67 Lockable doors % 100.0% 100.0% 94.7% 94.3% 100.0% 95.7% n 1 1 16 29 11 57 Security guard % 100.0% 100.0% 84.2% 82.9% 78.6% 81.4% n 0 0 2 1 0 3 Alarm system % 0.0% 0.0% 10.5% 2.9% 0.0% 4.3% Total 1 1 19 35 14 70

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 4

3.4.2 Accessibility to power/electricity

Reliability of power/electricity

To assess reliability of power/electricity, we focused on sites that had not experienced any power blackout/outage during the month of February 2019. This is particularly important since the idea of the EMR scale up is to have a real-time data collection that would require power on a continuous basis. Figure 2 presents the findings and as shown only 30% of the sites did not experience power blackouts/outages during the month. All the two referral sites (Kakamega and Vihiga) did not experience any power problem, however other facilities did experience blackouts/outages; 79% of the sub county hospitals blackouts as were 71% and 61% of the health centres and dispensaries, respectively.

In summary, the power situation in most of the sites is unreliable and therefore adds credence to the need of using tablets complemented by power backup facilities in situations of prolonged blackouts.

Figure 2 % distribution of sites that did not experience any power blackout/outage in February 2019 by site type 120

100 100 100

% 60

39 40 29 30 21 20

0 Regional referral County referral Subcounty Health centre Dispensary Overall hospital hospital hospital

Presence of a power source in selected SDPs

Availability of a power source (socket) in a service delivery point is essential as it allows devices to be connect to the primary power supply. As shown in figure 3, power sockets were available in over 90% of the SDPs. Ninety seven percent of the CCCs had sockets as were 96% of the laboratories.

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 5

Figure 3 % distribution of departments with a working power source 98

97 97

96 96

% 94 94

93 93 93 93

91 CCC TB Clinic MCH Labortory Pharmacy Outpatient

Availability of source of power backup

Table 6 below presents a distribution of sites by source of power backup. Power backup is a critical requirement in a situation where power is unreliable. As indicated earlier, power is generally unreliable in most of the assessed facilities. Overall, 16% of the sites did not have any source of power backup at all. A small proportion, 8.6% had UPS for power backup way below expectation as this would be more likely source of backup in the current setup where desktop computers are being used for EMR. The bigger facilities reportedly used generators for power backup including 63% of the sub county hospitals.

The smaller facilities, health centres had a preference of solar power as a backup with a quarter reportedly used solar as was 36% of the dispensaries.

Table 6 % Distribution of sites by source of power backup

Backup Type of site source RRH (n=1) CRH (n=1) SC Hospital Health Dispensary Total (N=70) (n=19) centre (n=14) (n=35) None 0.0% 0.0% 5.3% 25.7% 7.1% 15.7%

Generator 100.0% 100.0% 63.2% 8.6% 7.1% 25.7%

Solar 0.0% 0.0% 21.1% 25.7% 35.7% 25.7%

UPS 0.0% 0.0% 10.5% 11.4% 0.0% 8.6%

Availability of voltage stabilizers

Voltage stabilizers are necessary for the protection of EMR equipment more so in an environment where power outage and fluctuations are common like in the assessed sites. Even though the two

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 6 referral facilities all had voltage stabilizers, overall they were not common as 21% of the sites had as shown in figure 4.

Figure 4 % distribution of sites with available voltage stabilizers by site type 120

100 100 100

% 60

40 32 29 21 20 11

0 Regional County referral Subcounty Health centre Dispensary Overall referral hospital hospital hospital

3.4.3 Availability of equipment (computers)

Figure 5 has a distribution of computers by facility types. Overall, 93% of the assessed sites had at least a computer for HIS related activities. As shown all the hospitals had at least a computer while 94% and 79% of the health centers and dispensaries had at least a computer, respectively.

Figure 5 % distribution of sites with computers (at least) by site type 120

100 100 100 100 94 93

79 80

% 60

0 Regional County referral Subcounty Health centre Dispensary Overall referral hospital hospital hospital

Table 7 provides details of the number of computers in service delivery points in each of the type of sites. As shown about two thirds (140) of the computers were in CCCs followed by the pharmacy that had 40 computers.

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 7

Table 7 Distribution of computers by department/area by site type

Type of site

Department Regional County Sub county Health Dispensary Total Referral Referral hospital Centre Hospital Hospital

CCC 14 1 68 52 5 140

MCH 3 2 8 10 2 25

Outpatient 1 2 27 3 0 33

Pharmacy 4 5 24 6 1 40

TB clinic 2 0 2 2 0 6

3.4.4 Accessibility to voice and data communication facilities

Table 8 presents a distribution of sites by mode of official voice communication, in this case the official cellphone. As shown, only 44% of the sites had and used an official cellphone for voice communication. The two referral sites had official cellphone, 63% of the sub county hospitals also had and a smaller proportion (37%) of the health centres. Besides a cellphone, Kakamega referral hospital had a landline for official communication.

Table 8 Mode of voice communication by type of site

Type of site

Department Regional County Sub county Health Dispensary Total Referral Referral hospital Centre Hospital Hospital

n 1 1 12 13 6 31 Official cellphone % 100.0% 100.0% 63.2% 37.1% 42.9% 44.3%

Total 1 1 19 35 14 70

Availability of wide area network (WAN)

Most (89%) of the sites had some type of facility for wide area network (WAN). As shown in table 9, the commonest was the personal cellphone modem which unfortunately may not be sustainable. Only a fifth (21%) of the sites had official cellphone modems and these were mainly sub county hospitals and health centres.

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 8

Table 9 Distribution of Sites by WAN available by type of site

Type of site

WAN type Regional County Sub county Health Centre Dispensary Total % Referral Referral hospital Hospital Hospital None 0 0 4 3 1 8 11.4% Dedicated line 1 1 0 0 0 1 1.4% Digital leased line 0 0 0 0 2 2 2.9% Landline Modem 0 0 1 1 0 2 2.9% Official cellphone 0 0 7 7 1 15 21.4% Modem Other 0 0 2 3 1 6 8.6% Personal cellphone 1 0 5 21 9 36 51.4% Modem Total 1 1 19 35 14 70 100%

Availability of local area network (LAN)

Figure 6 presents a distribution of sites by availability of local area network (LAN) in selected departments. Seventy nine percent of the CCC had LANS and so were 67% of the TB clinics and MCHs, respectively. Less than 30% of the other departments (laboratory, pharmacy and outpatient) had LANS.

Figure 6 % distribution of departments with LAN 90 79 80

70 67 67

50 % 40

30 26 23 20 16

0 CCC TB Clinic MCH Labortory Pharmacy Outpatient

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 9

3.5 Staffing and training in EMR

Information was collected on 1155 staff in the 5 SDP’s of interest regarding training in EMR, their knowledge and application of EMR and the status of selected competencies. Figure 7 and table 10 present a distribution of sites by percent trained staff. Overall, only 30% (of the 1155) had been trained with Vihiga county referral hospital having 48% of their staff trained. Proportions of trained staff for the other facility type were below 35%, with the dispensaries at 21%.

Figure 7 % distribution of sites with EMR trained staff by site type 60

50 48

40 33 30 28 28

% 30

21 20

0 Regional referral County referral Subcounty Health centre Dispensary Overall hospital hospital hospital

Table 10 % distribution of EMR trained staff by type of site

Staffing Number of Staff Number Trained % Trained overall on EMR

Regional Referral Hospital 58 16 28%

County Referral Hospital 50 24 48%

Subcounty hospital 430 141 33%

Health centre 446 124 28%

Dispensary 171 36 21%

Total 1155 341 30%

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 10

3.6 Data concordance

To assess familiarity with existing EMR system, the assessment team randomly sampled 10 patient files, the current disease register and latest monthly report and evaluated for completeness1 of the data and whether well filled2. As shown in figure 8, overall 92% of the sites assessed sites had completely filled MOH data capture forms. Generally, data concordance was good across site types.

Figure 16 % distribution of sites with complete and well filled forms by type of Site 120

100 94 100 91 92 92 80 80

% 60

0 Regional referral County referral Subcounty Health centre Dispensary Overall hospital hospital hospital

4. Conclusion

1. In most of the assessed health facilities, the TB clinic is integrated with the CCC with a few stand-alone TB Clinics.

2. Limited availability of stand-alone pharmacies and Lab rooms.

3. EMR systems and equipment's are mainly available in CCC’s.

4. There is strong management support for EMR systems

5. There exists space constraints mainly at the lower level health facilities.

6. There is low reliability of power supply and limited availability of power backup sources

7. There is low availability of official voice and data communication systems.

8. There is low staff training of EMR.

1 Completeness – a form was classified as complete when all the required data elements are captured and up to date. 2 Well filled – a form/register was classified as “well filled” when the information contained is correct and error free.

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 11

5. Report validation and County Engagement

The rapid assessment findings outlined above were shared with key stakeholders in a validation meeting held in Kakamega on 4th April 2019. Participants included the Chief Officer-health for Kakamega County, CHMT members from the 3 counties as well as representatives from HealthIT, KenyaHMIS, Tupime Kaunti, AMPATHplus and USAID. Input from the meeting was used to revise the minimum ICT requirements for EMR scale up.

County engagement meetings were held in Busia (16th April), Kakamega (17th April) and Vihiga (18th April). They were attended by select SCHMT and SCHMT members. A courtesy call was paid to Governor- Busia County and respective CECM- Health members for Kakamega and Vihiga counties. Feedback from these meetings helped improve information on minimum ICT requirements for EMR scale up. The meetings also identified roles and responsibilities for respective counties, PATH, Health IT, CMLAPs and Implementing partners in the EMR scale up. Each county meeting came up with a way forward. Embedded below are roles and responsibilities and way forward action points from the respective county engagement meetings.

Double click on the icons to open the Busia County way forward document and roles and responsibilities presentation. EMR ICT BUSIA Way Roles and forward.docx Responsibilities_16TH April 2019_Busia.pptx

Double click on the icons to open the Kakamega County way forward document and roles and responsibilities presentation. EMR ICT Kakamega Kakamega Roles Way forward.docx and Responsibilities_17TH April 2019.pptx

Double click on the icons to open the Vihiga County way forward document and roles and responsibilities presentation. EMR ICT Vihiga_ VIHIGA_ Roles and Way forward.docx Responsibilities_18TH April 2019.pptx

6. Minimum Requirements for EMR

To establish minimum requirements for EMR, PATH developed a costed list of equipment and supplies essential to setting up a functional EMR across several platforms (departments) including CCC, TB. MCH, Laboratory, Pharmacy, Inpatient and outpatient. In addition the following were also considered; the cost of installation and maintenance, training of service providers, and training equipment including tablets. Figure 11 has a schema of the proposed ICT infrastructure that guided determination of the minimum requirements.

An estimation was made for the number of units that would be required for each category of site (facility) starting with the regional referral hospital, county referral hospital, sub county hospitals, health centres and dispensaries. The end result is an estimate of the minimum cost for setting up and EMR in each type of site. Figure 12 provides the unit cost requirements for each type of site.

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 12

Figure 11 Proposed EMR ICT Infrastructure Specifications for Deployment

Figure 12 Minimum cost requirements for EMR per facility type $45,000 $40,727 $40,000 $37,580 $34,042 $35,000 $29,815 $30,000 $25,414 $25,000

$20,000

$15,000

$10,000

$5,000

$0 Regional referral County referral Sub county hospital Health Centre Dispensary hospital hospital

Please click object in next column to open a detailed list of equipment and supplies, installation and training items per site type PATH APHIAplus Western Facilities_EMR Infrastructure Deployment Minimum Requirement Total Costed Apr 2019.xlsx

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 13

7. Gap analysis

The gap analysis focused on collecting data on availability and status of selected equipment essential for a functioning EMR. First was ascertain whether there existed and EMR system and the platform. Then ascertaining the availability of selected items that included a router, switch, WAP, 9U cabinet, server (including specifications) and local area network (LAN). The analysis also looked at training of staff in EMR.

Availability of EMR system

Table 11 presents a distribution of sites by availability of an EMR system and the platform. As shown 57 (81%) of Sites had and EMR system that was running on the KenyaEMR platform, 37 (53%) of which were exclusively on KenyaEMR. Twenty (29%) sites had a combination of KenyaEMR and others like WebADT, CHIS and Funsoft. However, there was one Site that was on Smartcare.

Table 11 Distribution of Sites by availability and EMR system and platform

System/platform Number of Sites % KenyaEMR 37 52.9 KenyaEMR and WebADT 7 10.0 KenyaEMR, CHIS 2 2.9 KenyaEMR, CHIS, WebADT 5 7.1 KenyaEMR, WebADT 5 7.1 KenyaEMR, WebADT, CHIS, Funsoft 1 1.4 No System 12 17.1 Smartcare 1 1.4 Total 70 100.0

Availability of selected items

Table 12 provides a distribution of sites by availability of selected EMR equipment. As shown only one Site had a router, 56 (80%) had a switch but not PoE (power of Ethernet), and none had WAP. Further, no Site had a 9U cabinet though several sites had a 4U cabinet of which were fully utilized. Fifty seven (81%) of the Sites had servers of various capacities though majority were HP. A local area network (LAN) was present in 56 (80%) of the Sites; and slightly over half (51%) of the sites did not have a power back, however 16 and 17 sites had a generator and solar, respectively.

Please click object in next column for a site level total cost of deployment Gap analysis data-final.xlsx

From the gap analysis, it is evident that there are major gaps on most of the equipment including routers, WAP, 9U cabinets, LANs in other department except for CCCs and some MCH points of service. About half of the sites would need power backups.

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 14

Table 12 Distribution of sites by availability of selected EMR equipment Type of equipment Availability Number of Sites % (N=70) Cisco 800series 1 1.4 Router Not Available 69 98.6 Available but not PoE 56 80.0 Switch Dlink 24 port not PoE 1 1.4 Not Available 13 18.6 WAP Not Available 70 100.0 42U Cabinet 1 1.4 4U Cabinet Available fully utilized 13 18.6 9U cabinet Not Available 12 17.1 Not Available,4U cabinet available fully utilized 44 62.9 Faulty sever 1 1.4 HP Compaq Elite 8300 i5 8Gb Memory and 40 57.1 capacity of 500GB HP Elite 8300 i5 7.8GiB,500GB storage 11 15.7 Server HP Proliant ML 10 1 1.4 HP Proliant ML 310 16GB and 1TB storage 3 4.3 capacity No server 13 18.6 Available at the CCC 18 25.7 Available at the CCC,MCH 31 44.3 Available at the CCC,OPD,MCH 4 5.7 Local Area Network Available CCC,NHIF clinic, Pharmacy, 1 1.4 (LAN) Available at the CCC,MCH 1 1.4 Available OPD, MCH, inpatient, lab, pharmacy but 1 1.4 not at the CCC No LAN 14 20.0 Available 1 1.4 Generator 16 22.9 Power backup No power back up 36 51.4 Solar 17 24.3

8. Cost of EMR deployment

Following the gap analysis where individual site needs were assessed, a total cost of deployment was developed by facility type based on the minimum requirements as detailed above. Factors considered included number and type of equipment, supplies, number of staff and training needs. These were then costed for individual sites. Table 13 provides a summary of total cost of EMR deployment by type of Site. As shown, the total cost of EMR deployment in the 70 Sites is $2,243,361 with the health centres taking about half of this amount.

Figure 13 Total cost of EMR deployment per site type

Site type Number of sites Total deployment amount ($) Regional referral Hospital 1 $43,188 County Referral Hospital 6 $240,640 Sub County Hospital 13 $470,240 Health Centre 39 $1,190,796 Mission hospital 2 $60,648 Dispensary 9 $237,849 Total 70 $2,243,361

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 15

Please click object in next column for a full list of EMR deployment requirements (equipment and supplies, installation and training) per site PATH APHIAplus Western Facilities_EMR Infrastructure Deployment Needs Total Costed Apr 2019_final.xlsx type

Priority Health Facilities

The project employed a competitive process to identify vendors for supply and installation of ICT equipment for EMR scale up. Solar lighting equipment had not been included in the initial approved plan for this project. However, the equipment was identified by the 3 counties as a priority which had to be provided. The cost for this equipment was found to be very high. The available budget could therefore only accommodate equipment for 17 sites instead of the planned 70 sites, inclusive of solar lighting equipment.

Prioritized The detailed prioritized requirements for the 17 health facilities is attached. Procurement list by facility May 2019.xlsx Next Steps

The project awaits guidance from USAID on whether to include the solar lighting equipment for this procurement or to exclude it and cover all 70 health facilities as initially planned.

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 16

Annexes Annex 1 List of sites by total cost of EMR deployment

Site name Site type Amount ($) CGH - Kakamega Regional referral Hospital $43,188 Butere District Hospital County Referral Hospital $40,107 Iguhu District Hospital County Referral Hospital $40,107 Lumakanda District Hospital County Referral Hospital $40,107 Malava District Hospital County Referral Hospital $40,107 Matungu Sub District Hospital County Referral Hospital $40,107 Vihiga District Hospital County Referral Hospital $40,107 Alupe Sub District Hospital Sub County Hospital $36,172 Amukura Health Centre Sub County Hospital $36,172 Emuhaya Sub District Hospital Sub County Hospital $36,172 Hamisi District Hospital Sub County Hospital $36,172 Likuyani Sub District Hospital Sub County Hospital $36,172 Manyala Sub District Hospital Sub County Hospital $36,172 Matunda Sub District Hospital Sub County Hospital $36,172 Mautuma Sub District Hospital Sub County Hospital $36,172 Nambale Health Centre Sub County Hospital $36,172 Navakholo Sub District Hospital Sub County Hospital $36,172 Sabatia Health Centre Sub County Hospital $36,172 Shibwe Sub District Hospital Sub County Hospital $36,172 Sio Port District Hospital Sub County Hospital $36,172 Bukaya Health Centre Health Centre $30,590 Bukura Health Centre Health Centre $30,590 Bungasi Health Centre Health Centre $30,590 Bushiri Health Centre Health Centre $30,590 Chekalini Health Centre Health Centre $30,590 Chombeli Health Centre Health Centre $30,590 Ebusiratsi Health Centre Health Centre $30,590 Elwesero Health Centre Health Centre $30,590 Emusanda Health Centre Health Centre $30,590 Emusire Health Centre Health Centre $30,590 Esiarambatsi Health Centre Health Centre $30,590 Ileho Health Centre Health Centre $30,590 Ipali Health Centre Health Centre $30,590 Kambiri Health Centre Health Centre $30,590 Khwisero Health Centre Health Centre $30,590 Kilingili Health Centre Health Centre $30,590 Kongoni Health Centre Health Centre $30,590 Lukolis Health Centre Health Centre $30,590 Lupida Health Centre Health Centre $30,590 Lusheya Health Centre Health Centre $30,590 Mabole Health Centre Health Centre $30,590 Banja Health Centre Health Centre $30,590 Mabusi Mabusi Health Centre Health Centre $30,534 Madende Dispensary Health Centre $30,534 Makunga Health Centre Health Centre $30,534 Matete Health Centre Health Centre $30,534 Mbale Rural Health Training Centre Health Centre $30,534

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 17

Site name Site type Amount ($) Mumias Dispensary Health Centre $30,534 Namasoli Health Centre Health Centre $30,534 Serem Health Centre Health Centre $30,534 Shamakhubu Health Centre Health Centre $30,534 Shikunga Health Centre Health Centre $30,534 Shinyalu Health Centre Health Centre $30,534 Shiru Health Centre Health Centre $30,114 Shisaba Dispensary Health Centre $30,114 Shiseso Health Centre Health Centre $30,114 Shitsitswi Health Centre Health Centre $30,534 Tigoi Health Centre Health Centre $30,534 Vihiga Health Centre Health Centre $30,534 Kaimosi Mision Hospital Mission Hospital $30,114 Kima Mission Hospital Mission Hospital $30,534 Approved Dispensary Dispensary $25,868 Khaunga Dispensary Dispensary $25,868 Luanda Town Dispensary Dispensary $26,288 Lung'anyiro Dispensary Dispensary $26,288 Muhaka Dispensary Dispensary $26,288 Nabongo Dispensary Dispensary $27,127 Nangina Dispensary Dispensary $27,127 Shamberere Dispensary Dispensary $26,708 Shihome Dispensary Dispensary $26,288 Total $2,243,361

USAID KENYA (APHIAplus WESTERN KENYA), YEAR 9 EXTENSION EMR RAPID ASSESSMENT REPORT 18