analysis of performance and utilization … · analysis of performance and utilization of kangaroo...

ANALYSIS OF PERFORMANCE AND UTILIZATION OF KANGAROO

MOTHER CARE FOR PRE-TERM AND LOW BIRTH WEIGHT BABIES

DECEMBER 2013

PREPARED FOR MAISHA PROGRAMME BY:

NYINISAELI K. PALLANGYO

FINAL REPORT

Analysis of Performance and Utilization of Kangaroo Mother Care for Pre-term and Low Birth Weight Babies

– Maisha Programme

Page i

ACRONYMS AND ABBREVIATIONS

ANC Antenatal Care

DRCHCO District Reproductive and Child Health Coordinator

HMT Hospital Management Team

HR Human Resource

KMC Kangaroo Mother Care

LBW Low Birth Weight

MAISHA Mothers and Infants Safe Healthy Alive

MNCH District Reproductive and Child Health Coordinator

MOHSW Ministry of Health and Social Welfare

MOI/C Medical Officer In charge

N/A Not Applicable

RCHCO Reproductive and Child Health Coordinator

RMO Regional Medical Officer

RRCHCO Regional Reproductive and Child Health Coordinator

SC Save the Children

SC UK Save the children-United kingdom

SOW Scope of Work

TBC 1 Tanzania Broadcasting Corporation One

ToR Terms of Reference

TOT Training of Trainers

URT United Republic of Tanzania

USAID United States Agency for International Development



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TABLE OF CONTENTS

TABLE OF CONTENTS .........................................................................................................ii

LIST OF TABLES .................................................................................................................. vi

LIST OF FIGURES ............................................................................................................. viii

LIST OF ANNEXES ............................................................................................................ viii

1. INTRODUCTION ........................................................................................................... 1

1.1. BACKGROUND OF THE MAISHA PROGRAM .......................................................... 1

1.2. PROGRAM GOAL AND OBJECTIVES....................................................................... 1

1.3. PROGRAM AREAS .................................................................................................... 1

1.4. OBJECTIVE OF THE CONSULTANCY ASSIGNMENT ............................................. 2

1.5. SCOPE AND TASKS OF THE CONSULTANCY ASSIGNMENT ................................ 2

2. OVERVIEW OF PERFOMANCE ASSEMENT PROCEDURE ....................................... 4

2.1. SUPERVISION OF KMC ............................................................................................ 4

2.2. THE KMC SUPERVISION TEAM ............................................................................... 4

2.3. PREPARATION FOR SUPERVISION OF KMC ......................................................... 4

2.3.1. KMC Checklist ........................................................................................................ 4

2.3.2. Re-orientation to the KMC Supervision Checklist .................................................... 5

2.3.3. Assessment and Grading of a Performance Area ................................................... 5

2.3.4. General Health Facility Performance ...................................................................... 5

2.3.5. Provision of Feedback on Initial Assessment .......................................................... 5

2.3.6. Reporting of Assessment Results ........................................................................... 5

3. PERFORMANCE ASSESSMENT FOR MTWARA REGION ......................................... 6

3.1. BASIC INFORMATION ON MTWARA KMC ............................................................... 6

3.2. ASSESSMENT FROM SUPERVISION VISITS .......................................................... 6

3.2.1. First Supervision Visit on 06th August 2012 ............................................................ 6

3.2.2. Second Supervision Visit on 26th June 2012 .......................................................... 7

3.2.3. Average Performance from the two Supervision Visits ............................................ 7

3.2.4. Feedback from the Hospital Management ............................................................... 7

3.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE MTWARA FACILITY ........... 8

4. PERFORMANCE ASSESSMENT FOR RUVUMA REGION .......................................... 9

4.1. BASIC INFORMATION ON RUVUMA KMC UNIT ...................................................... 9

4.2. ASSESSMENT FROM SUPERVISION VISITS .......................................................... 9

4.2.1. First Supervision Visit on 16th March 2011 ............................................................. 9

4.2.2. Second Supervision Visit on 15th August 2012 ..................................................... 10

4.2.3. Third Supervision Visit on 14th Feb 2013 .............................................................. 11

4.2.4. Average Performance from the three Supervision Visits ....................................... 12

4.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE RUVUMA FACILITY ......... 12

5. PERFORMANCE ASSESSMENT FOR IRINGA REGION ........................................... 14

5.1. BASIC INFORMATION ON IRINGA KMC ................................................................ 14

5.2. ASSESSMENT FROM SUPERVISION VISITS ........................................................ 14

5.2.1. First Supervision Visit on 17th March 2011 ........................................................... 14

5.2.2. Second Supervision Visit on 4th June 2012 .......................................................... 15

5.2.3. Third Supervision Visit on 11th Feb 2013 .............................................................. 16


5.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE IRINGA FACILITY ............ 17



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6. PERFORMANCE ASSESSMENT FOR TABORA REGION ........................................ 18

6.1. BASIC INFORMATION ON TABORA KMC UNIT ..................................................... 18


6.2.1. First Supervision Visit on 17th March 2011 ........................................................... 18

6.2.2. Second Supervision Visit on 19th June 2012 ........................................................ 18

6.2.3. Third Supervision Visit on 14th January 2013 ....................................................... 19


6.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE TABORA FACILITY .......... 20

7. PERFORMANCE ASSESSMENT FOR MANYARA REGION ..................................... 21

7.1. BASIC INFORMATION ON MANYARA KMC UNIT .................................................. 21


7.2.1. First Supervision Visit on 11th May 2011 .............................................................. 21

7.2.2. Second Supervision Visit on 24th April 2013 ......................................................... 21

7.2.3. Third Supervision Visit on 24th April 2013 ............................................................. 22


7.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE MANYARA FACILITY ....... 23

8. PERFORMANCE ASSESSMENT FOR ARUSHA REGION ........................................ 24

8.1. BASIC INFORMATION ON ARUSHA KMC UNIT ..................................................... 24



8.2.2. Second Supervision Visit on 12th July 2012.......................................................... 24

8.2.3. Third Supervision Visit on 02nd April 2012 ............................................................. 25


8.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE ARUSHA FACILITY .......... 25

9. PERFORMANCE ASSESSMENT FOR KIGOMA REGION ......................................... 27

9.1. BASIC INFORMATION ON KIGOMA KMC UNIT ..................................................... 27



9.2.2. Second Supervision Visit on 21st May 2012 .......................................................... 27

9.2.3. Third Supervision Visit on 16th January 2013 ........................................................ 28


9.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE KIGOMA FACILITY........... 29

10. PERFORMANCE ASSESSMENT FOR ZANZIBAR ................................................. 31

10.1. BASIC INFORMATION ON ZANZIBAR KMC UNIT .............................................. 31

10.2. ASSESSMENT FROM SUPERVISION VISITS ..................................................... 31

10.2.1. First Supervision Visit on 23rd March 2012......................................................... 31

10.2.2. Second Supervision Visit on 06th November 2012 ............................................. 31

10.2.3. Average Performance from the two Supervision Visits ...................................... 32

10.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE ZANZIBAR FACILITY .... 32

11. PERFORMANCE ASSESSMENT FOR KAGERA ................................................... 34

11.1. BASIC INFORMATION ON KAGERA KMC UNIT ................................................. 34


11.2.1. First Supervision Visit on 14th May 2012 ............................................................ 34

11.2.2. Second Supervision Visit on 15th November 2012 ............................................ 35


11.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE KAGERA FACILITY ...... 36



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12. PERFORMANCE ASSESSMENT FOR MWANZA REGION .................................... 38

12.1. BASIC INFORMATION ON MWANZA KMC UNIT ................................................ 38


12.2.1. First Supervision Visit on 02nd May 2012 ........................................................... 38

12.2.2. Second Supervision Visit on 09th November 2012 ............................................. 39


12.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE MWANZA FACILITY ..... 40

13. PERFORMANCE ASSESSMENT FOR MARA REGION ......................................... 41

13.1. BASIC INFORMATION ON MARA KMC UNIT ...................................................... 41


13.2.1. First Supervision Visit on 07th May 2012 ............................................................ 41

13.2.2. Second Supervision Visit on 12th November 2012 .............................................. 42


13.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE MARA FACILITY ........... 43

14. PERFORMANCE ASSESSMENT FOR SHINYANGA REGION............................... 45

14.1. BASIC INFORMATION ON SHINYANGA KMC UNIT ........................................... 45


14.2.1. First Supervision Visit on 21st June 2012 ........................................................... 45

14.2.2. Second Supervision Visit on 09th January 2013 ................................................. 46


14.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE SHINYANGA FACILITY 47

15. PERFORMANCE ASSESSMENT FOR SINGIDA REGION ..................................... 48

15.1. BASIC INFORMATION ON SINGIDA KMC UNIT ................................................. 48


15.2.1. First Supervision Visit on 14th June 2012 ........................................................... 48

15.2.2. Second Supervision Visit on 13th December 2012 ............................................. 49


15.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE SINGIDA FACILITY ....... 50

16. PERFORMANCE ASSESSMENT FOR DODOMA REGION .................................... 51

16.1. BASIC INFORMATION ON DODOMA KMC UNIT ................................................ 51


16.2.1. First Supervision Visit on 11th June 2012 ........................................................... 51

16.2.2. Second Supervision Visit on 11th December 2012 ............................................. 52


16.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE DODOMA FACILITY ..... 53

17. PERFORMANCE ASSESSMENT FOR TANGA REGION ....................................... 54

17.1. BASIC INFORMATION ON TANGA KMC UNIT .................................................... 54


17.2.1. First Supervision Visit on 30th March 2012 ........................................................ 54

17.2.2. Second Supervision Visit on 29th January 2013 ................................................ 54


17.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE TANGA FACILITY ......... 55

18. PERFORMANCE ASSESSMENT FOR MBEYA REGION ....................................... 57

18.1. BASIC INFORMATION ON MBEYA KMC UNIT ................................................... 57


18.2.1. First Supervision Visit on 09th September 2011 ................................................ 57



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18.2.2. Second Supervision Visit on 21st August 2012 .................................................. 57

18.2.3. Third Supervision Visit on 18th February 2013 ................................................... 58

18.2.4. Average Performance from the three Supervision Visits .................................... 58

18.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE MBEYA FACILITY ......... 58

19. PERFORMANCE ASSESSMENT FOR RUKWA REGION ...................................... 60

19.1. BASIC INFORMATION ON RUKWA KMC UNIT ................................................... 60


19.2.1. First Supervision Visit on 23rd August 2012 ...................................................... 60

19.2.2. Second Supervision Visit on 20th February 2013 ............................................... 61


19.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE RUKWA FACILITY ........ 62

20. PERFORMANCE ASSESSMENT FOR KILIMANJARO REGION ........................... 63

20.1. BASIC INFORMATION ON KILIMANJARO KMC UNIT ........................................ 63


20.2.1. First Supervision Visit on 26th July 2012 ........................................................... 63

20.2.2. Second Supervision Visit on 21st May 2013 ....................................................... 63


20.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE KILIMANJARO FACILITY

……………………………………………………………………………………………..65

21. PERFORMANCE ASSESSMENT FOR DAR ES SALAAM REGION ...................... 66

21.1. BASIC INFORMATION ON DAR ES SALAAM KMC UNIT ................................... 66


21.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE DAR ES SALAAM

FACILITY ............................................................................................................................ 67

22. GENERAL PERFORMANCE OF THE 19 HEALTH FACILITIES PROVIDING KMC 68

22.1. RANKING OF REGIONAL PERFORMANCES ..................................................... 68

22.2. PERFORMANCE PER GRADING CRITERIA ....................................................... 69

23. PERFORMANCE PER ASSESSMENT AREAS ...................................................... 70

23.1. KMC SITE PHYSICAL SETTING .......................................................................... 70

23.2. KMC SERVICES ARE INSTITUTIONALIZED IN THE FACILITY .......................... 70

23.3. THE PROVIDER PREPARES THE MOTHER AND BABY FOR KMC .................. 70

23.4. THE PROVIDER ENSURES THAT THE BABY IS FED CORRECTLY ................. 71

23.5. THE PROVIDER MONITORS THE BABY RECEIVING KMC CORRECTLY ......... 71

23.6. INFECTION PREVENTION AND CONTROL PRACTICES ARE ADHERED ........ 71

23.7. THE MOTHER & HER FAMILY ARE SUPPORTED ............................................. 72

23.8. THE BABY IS DISCHARGED ACCORDING TO GUIDELINES ............................ 72

23.9. THE BABY RECEIVES REGULAR FOLLOW UPS ............................................... 72

23.10. KMC RE-ADMISSION CRITERIA FOLLOWED .................................................... 73

23.11. DISCONTINUATION OF BABIES FROM KMC ..................................................... 73

23.12. KMC SERVICES ARE KNOWN TO THE COMMUNITY ....................................... 74

23.13. MONITORING AND EVALUATION OF KMC SERVICES ..................................... 74

24. ANALYSIS OF DOCUMENTED DATA .................................................................... 75

24.1. BEST PERFORMERS IN DATA DOCUMENTATION ........................................... 75

24.2. ADMISSION OF LBW BABIES AT KMC SITES .................................................... 75

24.3. BABIES DISCHARGED FROM KMC WARD ........................................................ 75

24.4. DEATH OF BABIES AT KMC SITES .................................................................... 76



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24.5. MOTHERS ABSCONDED WITH THEIR PRE-TERM AND LBW BABIES FROM

KMC WARD ........................................................................................................................ 77

24.6. BABIES LOST TO FOLLOW UP ........................................................................... 77

24.7. PERIOD OF STAY OF BABIES AT KMC SITES ................................................... 78

25. CONCLUSION AND RECOMMENDATIONS ........................................................... 79

25.1. CONCLUSION ...................................................................................................... 79

25.2. RECOMMENDATIONS ............................................ Error! Bookmark not defined.

LIST OF TABLES

Table 1-1: Grading System for Assessment of Performance Area......................................... 5

Table 3-1: Basic Information on Mtwara KMC Unit ................................................................ 6

Table 3-2: Mtwara Challenges and Agreed Action ................................................................ 6

Table 3-3: Average Performance for Mtwara KMC Unit ......................................................... 7

Table 3-4: Information on Newborns including Pre-term and LBW Babies in Mtwara Facility 8

Table 4-1: Basic Information on Ruvuma KMC Unit .............................................................. 9

Table 4-2: Ruvuma Challenges and Agreed Action ............................................................. 11

Table 4-3: Average Performance for Ruvuma KMC Unit ..................................................... 12

Table 4-4: Information on Newborns including Pre-term and LBW Babies in Ruvuma Facility

........................................................................................................................................... 12

Table 5-1: Basic Information on Iringa KMC Unit ................................................................. 14

Table 5-2: Iringa Challenges and Agreed Action ................................................................. 15

Table 5-3: Average Performance for Iringa KMC Unit ......................................................... 16

Table 5-4: Information on Pre-term and LBW Babies in Iringa Facility ................................. 17

Table 6-1: Basic Information on Tabora KMC Unit .............................................................. 18

Table 6-2: Tabora Challenges and Agreed Action ............................................................... 19

Table 6-3: Average Performance for Tabora KMC Unit ....................................................... 19

Table 6-4: Information on Newborns including Pre-term and LBW Babies in Tabora Facility

........................................................................................................................................... 20

Table 7-1: Basic Information on Manyara KMC Unit ............................................................ 21

Table 7-2: Manyara Challenges and Agreed Action ............................................................ 22

Table 7-3: Average Performance for Manyara KMC Unit .................................................... 22

Table 7-4: Information on Newborns including Pre-term and LBW Babies in Manyara Facility

........................................................................................................................................... 23

Table 8-1: Basic Information on Arusha KMC Unit .............................................................. 24

Table 8-2: Arusha Challenges and Agreed Action ............................................................... 24

Table 8-3: Average Performance for Arusha KMC Unit ....................................................... 25

Table 8-4: Information on Newborns including Pre-term and LBW Babies in Arusha Facility

........................................................................................................................................... 26

Table 9-1: Basic Information on Kigoma KMC Unit ............................................................. 27

Table 9-2: Kigoma Challenges and Agreed Action .............................................................. 28

Table 9-3: Average Performance for Kigoma KMC Unit ...................................................... 29

Table 9-4: Information on Pre-term and LBW Babies in Kigoma Facility.............................. 30

Table 10-1: Basic Information on Zanzibar KMC Unit .......................................................... 31

Table 10-2: Average Performance for Zanzibar KMC Unit .................................................. 32

Table 10-3: Information on Pre-term and LBW Babies in Zanzibar Facility .......................... 32



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Table 11-1: Basic Information on Kagera KMC Unit ............................................................ 34

Table 11-2: Kagera Challenges and Agreed Action ............................................................. 34

Table 11-3: Average Performance for Kagera KMC Unit ..................................................... 36

Table 11-4: Information on Pre-term and LBW Babies in Kagera Facility ............................ 36

Table 12-1: Basic Information on Mwanza KMC Unit .......................................................... 38

Table 12-2: Mwanza Challenges and Agreed Action ........................................................... 38

Table 12-3: Average Performance for Mwanza KMC Unit ................................................... 39

Table 12-4: Information on Newborns including Pre-term and LBW Babies in Mwanza

Facility ................................................................................................................................ 40

Table 13-1: Basic Information on Mara KMC Unit ............................................................... 41

Table 13-2: Mara Challenges and Agreed Action ................................................................ 42

Table 13-3: Average Performance for Mara KMC Unit ........................................................ 43

Table 13-4: Information on Pre-term and LBW Babies in Mara Facility ............................... 43

Table 14-1: Basic Information on Shinyanga KMC Unit ....................................................... 45

Table 14-2: Shinyanga Challenges and Agreed Action ....................................................... 45

Table 14-3: Shinyanga HMT reaction to Outstanding Challenges ....................................... 46

Table 14-4: Average Performance for Shinyanga KMC Unit................................................ 46

Table 14-5: Information on Newborns and LBW Babies in Shinyanga Facility ..................... 47

Table 15-1: Basic Information on Singida KMC Unit ............................................................ 48

Table 15-2: Singida Challenges and Agreed Action ............................................................ 48

Table 15-3: Average Performance for Singida KMC Unit .................................................... 49

Table 15-4: Information on Newborns and Pre-term and LBW Babies in Singida Facility .... 50

Table 16-1: Basic Information on Dodoma KMC Unit .......................................................... 51

Table 16-2: Dodoma Challenges and Agreed Action ........................................................... 52

Table 16-3: Average Performance for Dodoma KMC Unit ................................................... 52

Table 16-4: Information on Newborns including Pre-term and LBW Babies in Dodoma

Facility ................................................................................................................................ 53

Table 17-1: Basic Information on Tanga KMC Unit ............................................................. 54

Table 17-2: Average Performance for Tanga KMC Unit ...................................................... 55

Table 17-3: Information on Newborns including Pre-term and LBW Babies in Tanga Facility

........................................................................................................................................... 56

Table 18-1: Basic Information on Mbeya KMC Unit ............................................................. 57

Table 18-2: Average Performance for Mbeya KMC Unit ...................................................... 58

Table 18-3: Information on Newborns including Pre-term and LBW Babies in Mbeya Facility

........................................................................................................................................... 59

Table 19-2: Sumbawanga Challenges and Agreed Action .................................................. 60

Table 19-2: Average Performance for Rukwa KMC Unit ..................................................... 61

Table 19-3: Information on Newborns including Pre-term and LBW Babies in Rukwa Facility

........................................................................................................................................... 62

Table 20-2: Average Performance for Kilimanjaro KMC Unit ............................................... 64

Table 20-3: Information on Newborns including Pre-term and LBW Babies in Kilimanjaro

Facility ................................................................................................................................ 65

Table 21-1: Basic Information on Dar es Salaam KMC Unit ................................................ 66

Table 21-2: Performance Assessment for Dar es Salaam KMC Unit ................................... 67

Table 21-3: Information on LBW Babies in Dar es Salaam Facility ...................................... 67

Table 22-1: Overall ranking of health facility performances in the 19 selected regions ........ 68



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Table 22-2: Performance per Grading Criteria..................................................................... 69

Table 23-1: Assessment of KMC Sites Physical Setting ...................................................... 70

Table 23-2: Assessment of Institutionalizing KMC Services in Facility ................................ 70

Table 23-3: Assessment in Preparing the Mother and Baby for KMC .................................. 70

Table 23-4: Assessment in Ensuring that the Baby is Fed Correctly ................................... 71

Table 23-5: Assessment in Provider Monitoring the Baby receive KMC Correctly ............... 71

Table 23-6: Assessment in Adherence to Infection Prevention and Control Practices ......... 71

Table 23-7: Assessment on the Mother and her Family being supported ............................ 72

Table 23-8: Assessment in discharging the Baby from the Facility ...................................... 72

Table 23-9: Assessment on Regular Follow Up to Babies ................................................... 73

Table 23-10: Assessment on Re-admission Criteria ............................................................ 73

Table 23-11: Assessment on Discontinuation of Babies ...................................................... 73

Table 23-11: Assessment on Awareness of KMC Services ................................................. 74

Table 23-11: Assessment on Monitoring and Evaluation ..................................................... 74

Table 24-1: Admission of LBW Babies at KMC Sites........................................................... 75

Table 24-2: Discharge of Babies from KMC Sites ............................................................... 76

Table 24-3: Death of Babies at KMC Sites .......................................................................... 76

Table 24-4: Abscondees at KMC Sites ................................................................................ 77

Table 24-5: Babies Lost to Follow up .................................................................................. 77

Table 24-2: Period of Stay of Babies at KMC Sites ............................................................. 78

LIST OF FIGURES

Figure 1-1: Map of the URT Showing Program Areas ........................................................... 2

LIST OF ANNEXES

ANNEX 1: Sample Checklist



Page 1

1. INTRODUCTION

1.1. BACKGROUND OF THE MAISHA PROGRAM

The Mothers and Infants Safe Healthy Alive (MAISHA) Programme is a USAID funded

programme with Jhpiego as the lead, working with the Ministry of Health and Social Welfare

(MOHSW), Save the Children (SC) and several other partners. Through MAISHA support,

SC has taken a lead role in establishing Kangaroo Mother Care (KMC) in 19 regional sites in

Tanzania. This includes providing technical and materials support, and monitoring the

delivery of KMC services and the standard and quality of care for pre-term/low birth weight

babies.

The implementation of KMC in Tanzania started in July 2009 and was anticipated to end in

June 2013 but has been extended to December 2013, to mark the fifth year of funding.

1.2. PROGRAM GOAL AND OBJECTIVES

The overall goal of KMC implementation is to contribute towards reduction in newborn

deaths due to pre-term complications.

The main objective is to support the MOHSW to roll out KMC services in selected regions in

Tanzania mainland and Zanzibar through:

Awareness raising of hospital management teams to establish their support and

ownership of these services

Capacity development of health workers for provision of quality services, health

system strengthening, including provision of basic supplies, tracking the utilization of

KMC services and continuous mentoring of trained staff.

1.3. PROGRAM AREAS

In close collaboration with the MoHSW, SC has supported the establishment of KMC sites in

16 selected regional hospitals in Tanzania mainland namely: Mtwara, Arusha, Kilimanjaro,

Tanga, Manyara, Iringa, Ruvuma, Rukwa, Mara, Mwanza, Shinyanga, Tabora, Kigoma,

Kagera, Singida, Dodoma, two sites at health centre level in Mbeya and Dar-es-Salaam and

one in the maternity hospital in Zanzibar. In total, there are 19 sites as shown on the figure

below:



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Figure 1-1: Map of the URT Showing Program Areas

1.4. OBJECTIVE OF THE CONSULTANCY ASSIGNMENT

The specific objectives of this consultancy are to:

a) By using statistical tools for analysis and presentation, analyze, interpret and present programme data on utilization of KMC services

b) Conduct qualitative / quantitative analysis of the data on performance monitoring for quality improvement and document findings

1.5. SCOPE AND TASKS OF THE CONSULTANCY ASSIGNMENT

The Consultant is expected to undertake the following tasks:

a) Hold discussions with the MAISHA Programme Manager regarding details of data analysis work before starting the job.

b) Meet with the MAISHA Programme Manager to discuss the Consultant ToR and SOW and signing of the contract agreement with the HR team prior to engagement.

c) Create a narrative report of the data and formulate conclusion



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d) Prepare and submit a draft report of the data on the 10th of December 2013 to the Manager MNCH – SCI Tanzania for discussion, comments and further inputs towards final version.

e) The data analysis work submitted to Save the Children under this ToR is the property of Save the Children and cannot be submitted, distributed to or used by any other party, unless arranged otherwise;

f) The consultant is obligated to work within the required deadlines and be available to Save the Children for comments and corrections.

g) The final report should be submitted on the 15th of December 2013



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2. OVERVIEW OF PERFOMANCE ASSEMENT PROCEDURE

2.1. SUPERVISION OF KMC

Supervision for KMC for pre-term and low birth weight babies was divided into two parts.

First part was the internal supervision done by the leaders of the health facilities and the

second part was the external supervision done by supervisors from outside the health

facility. Internal supervision was conducted monthly whereas the external supervision was

done four times a year (once every quarter). Supervision was done at health facilities

providing KMC services and health care providers trained on KMC provision.

2.2. THE KMC SUPERVISION TEAM

Internal supervision

The internal supervision team comprised of:

Medical Officer Incharge

Matron

Nurse and Doctor in charge of Post natal ward/Neonatal ward

Nurse Incharge of Labour ward

External supervision

The external supervision team comprised of supervisors from the following sections:

Representative from the Ministry of Health and social welfare

Representative from the Region

Representative from respective Council

Representative from Non-Governmental Organization (KMC partner)

2.3. PREPARATION FOR SUPERVISION OF KMC

Before conducting the supervision, the supervision team prepared the following:

schedule/supervision plan

set clearly defined objectives

communicated to the supervisee and administrative authority of the health

facility to be supervised.

supervisory tools; KMC checklist , equipment and supplies

reviewed previous supervision reports.

logistics and other resources.

2.3.1. KMC Checklist

The KMC checklist was the most important tool in the supervision exercise. The checklist

was used to assess 13 performance areas. A sample checklist is attached to this report as

Annex 1-1



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2.3.2. Re-orientation to the KMC Supervision Checklist

The supervision team went through the criterion for verification of the performance areas one

by one. If the criterion had been followed, the supervisor would put a tick (√) on the Yes

column a tick (√) on a No column if the criterion had not been followed.

2.3.3. Assessment and Grading of a Performance Area

A grading system was used to estimate the percentage for Yes for each of the performance

areas assessed as shown in the table below:

Table 1-1: Grading System for Assessment of Performance Area

Assessment Percentage Score

Very good 67 – 100 3

Good 33 – 66 2

Weak Less than 33 1

2.3.4. General Health Facility Performance

There were 13 performance areas developed for assessment in each health facility. To get

the general performance of each health facility, the following procedure was followed:

all scores awarded for each performance area were summed up,

the total score was divided by 39, (13 performance areas x 3. Three (3) was

the highest score that could be awarded for any given performance area),

the result was multiplied by 100 to get a percentage and

the overall grading was then concluded as very good, good or weak as per

the grading system above.

2.3.5. Provision of Feedback on Initial Assessment

The supervisors provided feedback as soon as they completed the assessment to the health

providers who were assessed and to the in-charges of various sections (labour, postnatal

and paediatric wards, RCH, store, pharmacy, laboratory, matron/patron and medical officer

in-charge). Feedback was provided immediately on performance areas that had been done

well by congratulating and encouraging them to keep up. Feedback on poorly done areas

was given next with suggestions for improvement provided.

2.3.6. Reporting of Assessment Results

An immediate report summarizing the strengths, major problems or weaknesses, the actions

agreed (between the supervisor and health workers supervised) to solve weaknesses, time

frame, responsible person to ensure that the problems are solved was prepared and

submitted to the management of the hospital, SC and to the MoHSW.



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3. PERFORMANCE ASSESSMENT FOR MTWARA REGION

3.1. BASIC INFORMATION ON MTWARA KMC

The KMC services in Mtwara region are provided at the Ligula Regional Hospital. The basic

information about the facility is as shown in the table below as per records of the last

supervision visit.

Table 3-1: Basic Information on Mtwara KMC Unit

Item Description

Name of health facility

Ligula Regional Hospital

Type of health facility

Hospital

Location Mtwara Region, Mtwara Urban

Ownership

Government

Number of health providers trained

on KMC in the health facility

25: 20 trained by MAISHA, 4 by the Municipal Council

and 1 by Ifakara Health Institute

Health providers working in KMC

unit/ward

2 registered nurses and 1 trained medical attendant

Health providers followed up after

training

4 registered nurses

3.2. ASSESSMENT FROM SUPERVISION VISITS

During the project period, two (2) external supportive supervision visits were done on 06th

August 2012 (during year 4) and on 26th June 2013 (during year 5). No supervision visits

were made in Mtwara during year 1, 2 and 3.

3.2.1. First Supervision Visit on 06th August 2012

During the first supervision visit, the following observations were made after assessment of

all performance areas of the KMC:

Generally the performance of the KMC services was very good, with an overall

assessed performance of 87%.

There were a few challenges affecting performance of the KMC facility. These

challenges and the action agreed to address them are shown in the table below:

Table 3-2: Mtwara Challenges and Agreed Action

Challenge Action

Space limitation resulting to increased rate of mothers seeking early discharge

The Medical Officer In charge (MOI/C) to create more space for KMC by breaking an existing wall

Staffing level; acute shortage of skilled staff affecting most of the hospital departments / sections including the KMC unit

The MOI/C to liaise with the Municipality for a possible solution

Reporting; late submission due to workload of staff (one skilled staff can be allocated to manage maternity ward - postnatal and antenatal including neonatal and KMC unit)

The MOI/C to solve this and ensure the computer is working properly

Increasing referrals from neighbouring areas that do not practice KMC e.g Likombe

The MOI/C to liaise with the Municipality for a possible solution



Page 7

The population surrounding the regional hospital has not been sensitized on KMC services

3.2.2. Second Supervision Visit on 26th June 2012

During the second supervision visit, the following observations were made:

Generally the performance of the KMC services was still very good, with an overall

assessed performance of 100%.

Some challenges identified during the first supervision visit were being addressed

while others still remained un-addressed:

o Space limitation was still a problem although the HMT had increased the

occupancy from 4 to 6 beds.

o Staffing level was still not good

o Reporting was slowly improving

o Increasing referrals from neighbouring areas was still a challenge

3.2.3. Average Performance from the two Supervision Visits

The Mtwara KMC unit scored an average performance of 94% as shown in the table below:

Table 3-3: Average Performance for Mtwara KMC Unit

No. Performance Area 1st Visit 2nd Visit Average

1 KMC physical setting 2 3 2.5

2 KMC services are institutionalized in the facility 3 3 3

3 The provider prepares the mother and the baby for KMC 3 3 3

4 The provider ensures that the baby is fed correctly 3 3 3

5 The provider monitors the baby receiving KMC correctly 3 3 3

6 Infection prevention and control practices are adhered 3 3 3

7 The mother of the baby receiving KMC and her family are supported

3 3 3

8 The baby is discharged from the facility according to guidelines

3

3 3

9 The baby receives regular follow ups 3 3 3

10 KMC readmission criteria 3 3 3

11 Discontinuation of babies from KMC 3 3 3

12 KMC services are known to the community 0 3 1.5

13 Monitoring and evaluation of KMC services 2 3 2.5

Total Score 34 39 36.5

Percentage 87% 100% 94%

3.2.4. Feedback from the Hospital Management

Internal supervisors appreciated the supervision visits done by SC jointly with the MoH,

which they said were very supportive and educative.

The hospital team confirmed to the team of external supervisors that they are able to

continue and sustain the initiative by themselves. The team is also committed to addressing

performance areas found with weaknesses.

The hospital team suggested a refresher training / orientation on KMC for the QI team before

they perform quality assessment exercise of the hospital services.



Page 8

3.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE MTWARA FACILITY

During the project period, 1,515 newborn babies were admitted at the neonatal and/or the

postnatal wards. Out of this, 841(56%) were admitted in the KMC ward. Out of those

admitted in the KMC ward, 79% were discharged successfully, 5% died, 4% absconded

while 2% were lost to follow up as shown in the table below.

Table 3-4: Information on Newborns including Pre-term and LBW Babies in Mtwara

Facility

Description Consolidated figures from Aug 2009 to Nov 2013

Percentage Remarks

Newborn Admitted in Neonatal/postnatal ward

1,515 N/A

LBW admitted in neonatal/postnatal ward

539 N/A emphasis is on admission to KMC unit

LBW babies admitted in KMC ward

841 56% of total new born babies admitted at the facility

Total LBW babies 1,380 91% of total new born babies

admitted at the facility

LBW babies discharged from KMC ward

662 79% of LBW babies admitted in KMC

LBW babies died in KMC 39 5% of LBW babies admitted in KMC

LBW babies absconded from KMC ward


LBW babies who are lost to follow


Average days of stay in KMC ward

5 N/A

From the above analysis of information collected from the Mtwara site, 92 (10%) of babies

admitted in the KMC ward are not accounted for. This shows that the site does not keep

proper records of KMC services. It is also evident that there is need for KMC services in the

region as 1,380 babies (91%) out of the 1515 new born babies were pre-term and LBW

babies.



Page 9

4. PERFORMANCE ASSESSMENT FOR RUVUMA REGION

4.1. BASIC INFORMATION ON RUVUMA KMC UNIT

The KMC services in Ruvuma region are provided at the Songea Regional Hospital. The

basic information about the facility is as shown in the table below as per records of the last

supervision visit.

Table 4-1: Basic Information on Ruvuma KMC Unit

Item Description


Songea Regional Hospital


Hospital

Location Songea Region, Songea Urban

Ownership

Government



23: 21 health workers and 2 master trainers)


unit/ward

4


training

2


During the project period, three (3) external supervision exercises were done on 16th March

2011(during year 3), 15th August 2012 (during year 4) and on 14th Feb 2013 (during year 5).

No supervision visits were done in Ruvuma during year 1 and 2.

4.2.1. First Supervision Visit on 16th March 2011

The objective of the first supervision visit in Ruvuma was to:

1. Assess if quality KMC services were being implemented

2. Assess if equipments supplied by SC are well utilized

3. Identify challenges faced and solutions for improvements

4. Provide support and mentoring to the gaps identified.

Location and setting of the KMC unit

The unit was within post natal ward, with 6 beds capacity and enough space for

nurse’s duty station within the centre. Warm, well ventilated but needs renovation.

No toilets were in the KMC room or running water to wash hands for infection

control.

The KMC room did not meet KMC standards, however it was reported that the site

was established as a temporary measure, awaiting relocation to a new maternity

ward under construction

KMC Implementation

Found 3 mothers in the ward, one of them practicing KMC but 2 of them not.

One among the 2 had twins both lying on bed and came for follow up.

KMC Register well utilized.

Contact mobile phone numbers of mothers discharged from the site were recorded.

Observations on feeding and counselling techniques done, some improvement on

guiding mothers needed.



Page 10

Utilization of KMC Equipments

Wall thermometer and digital scale in place and in good working condition.

A manual operated weighing scale to supplement the digital one when need arises

was in place.

Low reading thermometers are still out of stock at the medical stores department

Gaps and Challenges

Lack of KMC supervisory skills – training will be conducted this year, will be

considered during training of health workers from the new regions

No schedule for on duty personnel or maternity organization chart (In charge of

Maternity, KMC person) - Advised to have a schedule in the ward

Shortage of skilled personnel

Mothers don’t turn up for follow up due to long distance from their homes to the

hospital

Some mothers abscond due to lack of food or money to buy food as they come from

far. The hospital doesn’t provide food

Remarks from the KMC team at Ruvuma

Requested for training to district health providers at all levels to enable follow up of

those who default on KMC follow-up visits

Requested for more health workers to be trained on KMC to increase knowledge and

skills hence improve quality of services provided.

Suggestions from the Visiting Team:

The visiting team however advised them to:

Do on the job training – those trained on KMC to train others

Encourage mothers on continuous skin to skin

Conduct community awareness on KMC method to gain support.

The visiting team suggested that they will also increase the frequency of supportive

supervision and mentoring

4.2.2. Second Supervision Visit on 15th August 2012

During the second supervision visit, the following observations were made after assessment

of all performance areas of the KMC:

Generally the performance of the KMC services was very good, with an overall

assessed performance of 97%.The hospital management has given great support to

KMC services and the team working in KMC unit was very committed, ensuring that

the services delivered were at the required standard.





Page 11

Table 4-2: Ruvuma Challenges and Agreed Action

Challenge Action

Due to the increasing demand for KMC services, the present space was not adequate

The hospital management would make

efforts to secure funds from different sources

, part of it would be used to expand the room

for KMC services

Mothers seek for early discharge due to social problem

The KMC team needs to conduct continuous

awareness creation and counseling to both

parents

Lack of KMC awareness resulting to poor or no support to mothers from family members

The hospital management and the KMC

team needs to conduct continuous

awareness creation and counseling to both

parents

Mothers lost for follow up due to distance or social problems

The hospital management to provide air time

to the MOI/C and the matron for

communication to trace and/or remind

mothers lost for follow up

4.2.3. Third Supervision Visit on 14th Feb 2013

During the third supervision visit, the following observations were made:

Generally the performance of the KMC services was still very good, with an overall

assessed performance of 100%. The performance was impressing and they had

done very well in most of the key performance areas.

Most of the performance areas found with gaps during the second supervision visits

had been dealt with:

o In two occasions the KMC team had done awareness creation, advocacy on

KMC services through media. On 13th Feb 2013 they were visited by the

media (TBC 1 and Mwananchi newspaper) accompanied by a visitor from

SC UK. The visitor wanted to learn more about KMC and provided gifts to

the mothers for their babies.

o The KMC team had put in place a workable mechanism of tracking mothers

lost to follow up by involving other health facilities within and outside

Songea Municipality.

o Space limitation was still a challenge. Efforts by the hospital management to

secure funds from external sources did not work as expected. However,

there were little funds that have secured for renovation of the toilets.

o Mothers seeking early discharge due to social problem were still a challenge

and awareness creation was required.

Mothers at the KMC unit had good access to current news from a radio donated by

one nurse working at the KMC unit (Marcelina Wella).

The hospital management was providing continuous support for provision of quality

KMC e.g. giving extra duty allowance for nurses working extra hours; this had really

motivated the staff.



Page 12

4.2.4. Average Performance from the three Supervision Visits

During the first visit, the checklist for assessment of performance areas from the MOHSW

was not ready. It was ready during the second and third visits. Based on the last two visits,

the Ruvuma KMC unit scored an average performance of 99% as shown in the table below:

Table 4-3: Average Performance for Ruvuma KMC Unit

No. Performance Area 1st Visit

2nd Visit

3rd Visit

Average

1 KMC physical setting

Checklis

t fo

r assessm

ent

had n

ot b

een p

rep

are

d

3 3 3

2 KMC services are institutionalized in the facility 3 3 3

3 The provider prepares the mother and the baby for KMC

3 3 3

4 The provider ensures that the baby is fed correctly 3 3 3

5 The provider monitors the baby receiving KMC correctly

3 3 3

6 Infection prevention and control practices are adhered

3 3 3


3 3 3


3 3 3

9 The baby receives regular follow ups 3 3 3


11 Discontinuation of babies from KMC 3 3 3


13 Monitoring and evaluation of KMC services 3 3 3


Percentage 0% 97% 100% 99%

4.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE RUVUMA FACILITY


postnatal wards. Out of this, 768(39%) were admitted in the KMC ward. Out of those

admitted in the KMC ward, 69% were discharged successfully, 8% died, 3% were

absconded while 10% were lost to follow as shown in the table below.

Table 4-4: Information on Newborns including Pre-term and LBW Babies in Ruvuma

Facility


Percentage Remarks


1,978 N/A












Page 13






7 N/A

Just like for Mtwara region, 80 (10%) of babies admitted in the Ruvuma KMC unit are not

accounted for. This shows that the site does not keep proper records of KMC services. It is

also evident that there is need for KMC services in the region as 1,370 babies (69%) out of

the 1978 new born babies were pre-term and LBW babies.



Page 14

5. PERFORMANCE ASSESSMENT FOR IRINGA REGION

5.1. BASIC INFORMATION ON IRINGA KMC

The KMC services in Iringa region are provided at the Iringa Regional Hospital. The basic


supervision visit:

Table 5-1: Basic Information on Iringa KMC Unit

Item Description


Iringa Regional Hospital


Hospital

Location Iringa Region, Iringa Urban

Ownership

Government



21: 20 health workers have formal training, and 1

master trainer


unit/ward

1


training

4


During the project period, three (3) external supervision exercises were done on 17th March

2011(during year 3), 04th June 2012 (during year 4) and on 11th Feb 2013 (during year 5). No

supervision visits were done in Iringa during year 1 and 2.


The objective of the first supervision visit in Iringa was to:

1. Assess if quality KMC services were being implemented

2. Assess if equipments supplied by SC are well utilized

3. Identify challenges faced and solutions for improvements

4. Provide support and mentoring to the gaps identified.

Location and setting of the KMC unit

There were 2 small KMC rooms located in Maternity ward. The rooms had 2 beds

each, minimal warmth and too small for a heater provided by SC.

The KMC rooms had containers for water to wash hands to prevent infection but

had no water neither soap

The KMC rooms did not meet KMC standards

Construction of a maternity ward was in plan, when ready the site would be shifted

KMC Implementation

During the visit, mothers were in the ward, some with babies in KMC position, but

some not.

Observations on feeding and counselling techniques for quality KMC service

implementation was not done, the focal person was assisting the doctor on a major

round



Page 15

Poor recording of data

Poor filing system

Utilization of KMC Equipments

Wall thermometer to monitor room temperature was not utilized.

Challenges

Lack of KMC supervisory skills; training would be conducted in the same year during

training of health workers from the new regions

Shortage of skilled staff

Mothers do not turn up for follow up due to long distance from their homes to the

hospital

Remarks from the visiting team

The team gave a feedback to the hospital matron. The matron promised to deal with

the problems identified

The team advised on the job training – those trained on KMC to train others

The team encourage mothers on continuous positioning babies skin to skin

The team advised the health workers to continue with Community awareness on

KMC method to gain support.

The visiting team committed themselves to increase the frequency of supportive

visits if budget allowed


During the second supervision visit, the following observations were made after assessment

of all performance areas of the KMC:

General performance of the KMC unit was improving compared to the situation

observed during the first visit on 17th March 2011. The overall assessed performance

was rated at 79% although cleanliness of KMC rooms was not being observed.



Table 5-2: Iringa Challenges and Agreed Action

Challenge Action

Space limitation In charge of Paediatric ward, Sr. Joyce Mbamba to make a close follow up

Lack of feeding tubes and graduated cups

Focal person to continue improvising cups for feeding Lack of support from HMT- trained staff on

KMC are not allocated to KMC unit

Matron to ensure that at least two trained staff allocated to work at KMC site during reshuffle

Communication gap between staff and HMT. KMC staff were not aware of the visit

HMT to address and look for appropriate solution on the existing communication gap

The community not well informed on KMC concept as a result of this men are reluctant to provide support to their wives enrolled at KMC units

HMT to ensure that KMC concept reaches the community through local media



Page 16

Hospital not providing food to all patients as a result of this, patients with no support from relatives are not willing to continue with KMC

KMC focal persons to be proactive in providing names of mother who require food assistance through the existing system

Mothers lost for follow up due to distance and lack of bus fare

HMT to set a mechanism for tracing mothers who are lost to follow up (example providing airtime to KMC focal persons) Shortage of staff and lack of commitment

to implement quality KMC

KMC to be integrated into other hospital services, and be recognized.

5.2.3. Third Supervision Visit on 11th Feb 2013

During the third supervision visit, it was observed that communication gap still continued to

exist with internal supervisors not being informed about the supervision visits on time by the

hospital management. General cleanliness of the KMC rooms, adherence to infection

prevention and control guidelines were also not being observed. Lack of public awareness

on KMC concept, staffing issues and poor follow up on mothers still persist. There is need

for commitment by the hospital management to support KMC services in order for KMC

quality services in the region to be realized. The overall assessment had however improved

to 92% compared to the previous assessment of 79%. The visiting team, however, are of the

opinion that the rated performance of 92% did not represent the actual situation on the

ground.


During the first visit, the checklist for assessment of performance areas from the MOHSW

was not ready. It was ready during the second and third visits. Based on the last two visits,

the Iringa KMC unit scored an average performance of 85% as shown in the table below:

Table 5-3: Average Performance for Iringa KMC Unit

No. Performance Area 1st

Visit 2nd

Visit 3rd

Visit Average

1 KMC physical setting

Checklis

t fo

r assessm

ent

had n

ot b

een p

rep

are

d

2 3 2.5

2 KMC services are institutionalized in the facility

3 3 3


3 3 3

4 The provider ensures that the baby is fed correctly

3 3 3


3 3 3


2 3 2.5


3 3 3


3 3 3

9 The baby receives regular follow ups

3 3 3


11 Discontinuation of babies from KMC

0 3 1.5

12 KMC services are known to the community

0 1 0.5

13 Monitoring and evaluation of KMC services

2 2 2

Total Score 30 36 33




Page 17

5.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE IRINGA FACILITY


postnatal wards. Out of this, 856 (30%) were admitted in the KMC ward. Out of those



Table 5-4: Information on Pre-term and LBW Babies in Iringa Facility


Percentage Remarks


2,808 N/A



LBW babies admitted in KMC ward 856 30% of total new born babies admitted at the facility








LBW babies who are lost to follow 25 3% of LBW babies admitted in KMC

Average days of stay in KMC ward 7 N/A

From the results above, 218 (26%) of babies admitted in the Iringa KMC unit are not

accounted for. This shows that the site does not keep proper records of KMC services.

There is demand for KMC services in the region as almost half (54%) of newborn babies

were Pre-term and LBW.



Page 18

6. PERFORMANCE ASSESSMENT FOR TABORA REGION

6.1. BASIC INFORMATION ON TABORA KMC UNIT

The KMC services in Tabora region are provided at the Kitete Regional Hospital. The basic


supervision visit:

Table 6-1: Basic Information on Tabora KMC Unit

Item Description


Kitete Regional Hospital


Hospital

Location Tabora Region, Tabora Urban

Ownership

Government



22: 20 health workers, 2 KMC master trainers


unit/ward

2


training

0


During the project period, three (3) external supervision exercises were done on 20th May

2011(during year 3), 19th June 2012 (during year 4) and on 14th January 2013 (during year

5). No supervision visits were done in Tabora during year 1 and 2.


During the first supervision visit in Tabora, it was observed that the KMC unit was not

performing well and there was no commitment and support from the hospital management. It

was also observed that there was a serious gap between the hospital management and

staff. Record keeping was also observed to be poor. After assessment of all performance

areas, the KMC unit scored 51% overall performance.


During the second visit, it was observed that there was a great improvement in providing

KMC services compared to the previous assessment done on 20th May 2011. The KMC

room was found clean and neat. Although the KMC staff at the site had not received any

formal KMC training, with the little knowledge they had got through peers had helped them to

make notable changes in the unit. After assessment of all performance areas, the KMC unit

scored 85% overall performance compared to 51% in the first visit.

There were a few challenges affecting performance of the KMC facility. These challenges

and the action suggested to address them are shown in the table below:



Page 19

Table 6-2: Tabora Challenges and Agreed Action

Challenge Action

The food provided by the hospital was not sufficient and was also not of good quality

The hospital management to be consulted on the provision of quality and sufficient food for patients including mothers in KMC unit who have no relatives or come from far. Most of the staff were not oriented on

basic KMC concepts

Implementation of KMC services needs to be

institutionalized (orient more staff during

continuing education sessions) and use of media

for mass communication

Space limitation for KMC services

KMC to be integrated into other hospital services,

and be recognized

Staff rotation affect quality of service and the overall KMC implementation

Matron to ensure that staff trained on KMC are

retained in the KMC unit

6.2.3. Third Supervision Visit on 14th January 2013

During the third visit, performance dropped suddenly from 85% to 43%. The KMC team

seemed to have no training on KMC services. From their assessment, the external

supervisors concluded that the KMC staff received little support from the hospital

management. A discussion to analyze the situation and identify factors that contributed to

declining performance was held with the MOI/C. The HMT agreed with the assessment

results of the external supervisors and committed themselves to:

Allocate 2 trained personnel to manage the KMC unit and work in collaboration with the KMC trainers (Dr. Ikandilo and the RCHCO Ms. Mbago)

Ensure that documentation of pre-term data and reporting is done appropriately and timely

Conduct internal supervision of the unit as per the MoHSW KMC guidelines


Based on the three visits, the Tabora KMC unit scored an average performance of 60% as

shown in the table below:

Table 6-3: Average Performance for Tabora KMC Unit


Visit 2nd

Visit 3rd

Visit Average

1 KMC physical setting 2 2 3 2.3

2 KMC services are institutionalized in the facility 2 2 1 1.7

3 The provider prepares the mother and the baby for KMC 2 3 3 2.7

4 The provider ensures that the baby is fed correctly 1 3 2 2.0

5 The provider monitors the baby receiving KMC correctly 0 3 0 1.0

6 Infection prevention and control practices are adhered 3 2 2 2.3


3 3 3 3.0


2 3 0 1.7

9 The baby receives regular follow ups 0 3 0 1.0

10 KMC readmission criteria 3 3 0 2.0



Page 20

11 Discontinuation of babies from KMC 2 2 0 1.3

12 KMC services are known to the community 0 2 2 1.3

13 Monitoring and evaluation of KMC services 0 2 1 1.0

Total Score 20 33 17 23.3

Percentage 51% 85% 44% 60%

6.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE TABORA FACILITY





Table 6-4: Information on Newborns including Pre-term and LBW Babies in Tabora

Facility


Percentage Remarks


2,431 N/A





Total LBW babies 1,304 54% of total new born babies admitted at the facility







Average days of stay in KMC ward 5 N/A

From the results above, 139 (17%) of babies admitted in the KMC unit are not accounted for.

This shows that the site does not keep proper records of KMC services. There is demand for

KMC services in the region as almost half (54%) of new born babies were LBW babies.



Page 21

7. PERFORMANCE ASSESSMENT FOR MANYARA REGION

7.1. BASIC INFORMATION ON MANYARA KMC UNIT

The KMC services in Manyara region are provided at the Babati Town Hospital. The basic


supervision visit:

Table 7-1: Basic Information on Manyara KMC Unit

Item Description


Babati Town Hospital


Hospital

Location Manyara Region, Babati Urban

Ownership

Government



21 health workers


unit/ward

0


training

0



2011(during year 3), 24th July 2012 (during year 4) and on 04th April 2013 (during year 5). No

supervision visits were done in Manyara during year 1 and 2.

7.2.1. First Supervision Visit on 11th May 2011

During the visit, it was established that the major challenge which affected KMC operations

was space. The KMC unit was located within the maternity ward and the space provided was

inadequate. Only 4 beds could be accommodated. After assessment of all performance

areas, the KMC unit scored 87% overall performance.

7.2.2. Second Supervision Visit on 24th April 2013

During the second visit, it was observed that the performance of the KMC unit had slightly

improved to an overall performance of 90% compared to 87% during the previous visit.

There were also a few challenges affecting performance of the KMC facility. These

challenges and the action agreed to address them during the visit are shown in the table

below:



Page 22

Table 7-2: Manyara Challenges and Agreed Action

Challenge Action

Mothers lost to follow up

HMT to approve use of 15,000 Tsh. from cost

sharing for communication

The hospital does not provide food, as a result mothers admitted in KMC unit request for early discharge because of lack of social support from their families.

HMT to discuss on provision of food to patients in

the next HMT meeting.

Data collection and reporting still done manually, as a result, it brings a lot of difficulties in timely submission of monthly reports to MoHSW / donors

Apply team work and use of available resources

for data management and reporting

7.2.3. Third Supervision Visit on 24th April 2013

During the third visit, performance dropped drastically from 90% recorded in the second visit

to 13%. The assessment results showed that KMC services in the facility had not been

institutionalized and integrated into other hospital services. Other major observations were:

There was no pre-counseling to mothers on KMC services

There was no health care provider allocated to support mothers on practicing KMC. As a result mothers did not have any knowledge regarding KMC with its benefits, KMC positioning, feeding, infection prevention and control and family involvement

Monitoring of vital signs on 12 hour basis and daily weighing of babies was not being done

The room was very untidy, un-hygienic and hand washing was not practiced

No trained staff to assist supervision team to review files and KMC register

The HMT was in agreement with the assessment results and they have committed

themselves to work on areas found with weaknesses.


Based on the three visits, the Manyara KMC unit scored an average performance of 63% as


Table 7-3: Average Performance for Manyara KMC Unit


2nd Visit

3rd Visit

Average




3 3 0 2.0



3 3 0 2.0



3 3 0 2.0

8 The baby is discharged from the facility according to 3 3 0 2.0



Page 23

guidelines







Percentage 87% 90% 13% 63%

7.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE MANYARA FACILITY

During the project period, 595 newborn babies were admitted at the neonatal and/or the




Table 7-4: Information on Newborns including Pre-term and LBW Babies in Manyara

Facility


Percentage

Remarks


595 N/A





Total LBW babies 578 97% of total new born babies admitted at the facility









3 N/A

There is demand for KMC services in the region as almost all (97%) of new born babies

were Pre-term and LBW. Only 5 (1%) of babies admitted in the unit died. This shows that the

Manyara unit has done well in ensuring that deaths of babies undergoing KMC are

minimized or avoided.



Page 24

8. PERFORMANCE ASSESSMENT FOR ARUSHA REGION

8.1. BASIC INFORMATION ON ARUSHA KMC UNIT

The KMC services in Arusha region are provided at the Mount Meru Regional Hospital. The


supervision visit:

Table 8-1: Basic Information on Arusha KMC Unit

Item Description


Mount Meru Regional Hospital


Hospital

Location Arusha Region, Arusha Urban

Ownership

Government



18 health workers


unit/ward

3


training

1



2011(during year 3), 12th July 2012 (during year 4) and on 02nd April 2013 (during year 5).

No supervision visits were done in Arusha during year 1 and 2.


The assessment results during the first visit ranked the KMC performance at 49%.The

hospital was under major rehabilitation and the KMC site had been temporarily shifted to

another location. Mothers were not practicing continuous KMC method due to lack of space

to accommodate all and probably due to insufficient support from KMC staff.

8.2.2. Second Supervision Visit on 12th July 2012

During the second visit, the performance of the KMC unit had improved from the previous

49% recorded in the first visit to 85%. Despite the improvement, several challenges still

existed. These challenges and the suggested actions are shown in the table below:

Table 8-2: Arusha Challenges and Agreed Action

Challenge

Action

Overcrowding due to space limitation Need for more space, at least 3 rooms each with

5 beds. Services could also be established in

other health facilities

No toilets and bathrooms for KMC

mothers

Need of a bathroom and a toilet for KMC mother

to avoid cross infection. The HMT to address this

issue



Page 25

Inadequate staff working at neonatal (1

qualified nurse and I medical attendant

per shift looking after 40 babies)

More trained staff to be allocated to neonatal unit

specifically those trained in KMC

No support of secretarial services

KMC services need to be strengthened through

additional support from HMT for provision of staff

to work at KMC site and secretarial services

Inadequate sockets and poor wiring

system in KMC room ( needed for

heaters and suction machine)

Follow up to be made

Inadequate access to KMC services and

follow up of KMC babies

KMC services to be extended to other health

facilities

8.2.3. Third Supervision Visit on 02nd April 2012

During the third visit, the performance of the KMC unit had further improved from the

previous 85% recorded in the second visit to 92%. Despite the improvement, most

challenges identified during the second visit still remained un-addressed. During the third

visit, it was also observed that resuscitation of babies with difficulty in breathing was not

being done at the KMC room. This resulted to delay of the resuscitation process and

exposed babies to cold environment.


Based on the three visits, the Arusha KMC unit scored an average performance of 75% as


Table 8-3: Average Performance for Arusha KMC Unit


Visit 2nd Visit

3rd Visit Average




2 3 3 2.7



2 2 3 2.3


2 3 3 2.7


0 3 3 2.0


3 3 3 3.0







Percentage 49% 85% 92% 75%

8.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE ARUSHA FACILITY





Page 26



Table 8-4: Information on Newborns including Pre-term and LBW Babies in Arusha

Facility


Percentage

Remarks


11,570 N/A


1,792 N/A emphasis is on admission to KMC unit












13 N/A

From the results above, 108 (21%) of babies admitted in the KMC unit are not accounted for.

This shows that the site does not keep proper records of KMC services. Although the

percentage of pre-term and LBW babies (20%) admitted at the facility is lower than other

regions, the number recorded over the project duration is significant. Arusha is the only site

where babies are unnecessarily kept at the KMC unit, with an average stay period of 13

days. The KMC staff need to be trained on guidelines for discontinuation of babies at the unit

so that babies continue with KMC at home. Only 6 (1%) of babies admitted in the unit died.

This shows that the Arusha unit has done well in ensuring that deaths of babies undergoing

KMC are minimized or avoided.



Page 27

9. PERFORMANCE ASSESSMENT FOR KIGOMA REGION

9.1. BASIC INFORMATION ON KIGOMA KMC UNIT

The KMC services in Kigoma region are provided at the Maweni Regional Hospital. The


supervision visit:

Table 9-1: Basic Information on Kigoma KMC Unit

Item Description


Maweni Regional Hospital


Hospital

Location Kigoma Region, Kigoma Urban

Ownership

Government



24: 20 health workers, and 2 KMC trainers


unit/ward

0


training

0



2011(during year 3), 21st May 2012 (during year 4) and on 16th January 2013 (during year 5).

No supervision visits were done in Kigoma during year 1 and 2.


The assessment results during the first visit ranked the KMC performance at 67%. There

was no specific space allocated for implementing KMC services at the hospital. The hospital

management was making an effort to secure a room for KMC services in the new neonatal

ward. KMC staff also needed a lot of support.

9.2.2. Second Supervision Visit on 21st May 2012

The overall assessment had improved to 72% compared to the previous assessment of 67%

recorded in the first visit. The visiting team, however, are of the opinion that the rated

performance of 72% did not represent the actual situation on the ground. The visiting team

observed that the performance of the site was poor. KMC services were still being

implemented within antenatal ward at a corner with 4 beds. The space did not provide

enough warmth, and was not conducive for implementing KMC services.

Despite the high score recorded in the checklist, many challenges still existed. These

challenges and the suggested actions are shown in the table below:



Page 28

Table 9-2: Kigoma Challenges and Agreed Action

Challenge Action

Internal communication gap

HMT to ensure internal communication between

RHMT and hospital improved

No trained staff allocated to work at KMC

Matron to allocate staff who will manage KMC site

on monthly basis

Lack of support from HMT in provision of quality KMC

Lack of support from HMT in provision of quality

KMC

Internal supportive supervision is not being done by the HMT as per the guidelines

Internal supportive supervision to be done on

monthly basis

There is no system to track mothers who are lost to follow up

HMT to establish a system to track mothers who

are lost to follow up

Space limitation

HMT to be consulted for a possibility to separate

the current space within antenatal ward by putting

a potable board.

Basic equipments for service provision not in place

HMT to ensure equipments for implementation of

KMC services are utilized

Late submission of report due to lack of secretarial and communication support

Secretarial and communication services should

consistently be available and KMC services to be

recognized and integrated with other services

Most of hospital staff are not aware of KMC services

KMC topics to be included in continuous

education sessions

9.2.3. Third Supervision Visit on 16th January 2013

During the third assessment, the performance of the KMC unit dropped drastically from 72%

to 8%. From the assessment results and discussions held between the visiting team and the

hospital management, it was revealed that:

The hospital management does not have sufficient information on KMC

project activities

There is lack of coordination of partners implementing maternal, new born

and child health activities in the region.

At the time of visit, no mothers were practicing KMC at the unit which was

located in the ante natal ward

At the time of visit, there was no change in the physical setting of the KMC

unit despite commitment made by the HMT during the last visit on 21st May

2012 to partition the unit and separate it from the ante natal services.

Due to lack of a KMC room, all pre-term babies with low birth weight are

admitted at the neonatal ward

Health service providers did not know where mothers of low birth weight

babies should practice KMC. As a result some mothers with their low birth

weight babies were being admitted to neonatal ward for KMC practice.

There was poor documentation of KMC services; the KMC register as well as

other KMC working tools were not being utilized.

Mothers with low weight babies admitted at the neonatal ward were not

counselled as per KMC guidelines, they were not educated on KMC position



Page 29

and lying on an elevated bed and there was no staff trained on KMC to

support the mother.

The RMO together with other hospital management team (MOI/C and

matron), committed themselves to make a partition at the antenatal ward for a

space to accommodate four beds. The Medical Officer in charge also

appointed a new KMC focal person; Ms Siyaleo Shilambele to work hand in

hand with the available KMC master trainers who are in the hospital to

revitalize the service. The MOI/C was advised by the supervisors to ensure

that the new focal person gets a formal KMC training through on the job

training where he agreed and requested for a feedback on the training plan by

Friday the 18th of January 2013.


Based on the three visits, the Kigoma KMC unit scored an average performance of 49% as


Table 9-3: Average Performance for Kigoma KMC Unit


Visit 2nd

Visit 3rd

Visit Average




2 3 0 1.7



2 2 0 1.3


3 2 0 1.7


3 3 0 2.0


3 2 0 1.7







Percentage 67% 72% 8% 49%

9.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE KIGOMA FACILITY







Page 30

Table 9-4: Information on Pre-term and LBW Babies in Kigoma Facility


Percentage Remarks


1,816 N/A














4 N/A

From the results above, the sum of babies discharged, babies who died, babies absconded

and babies lost to follow up exceeds the number of babies admitted at the KMC site by 10

(3%). This shows that the site does not keep proper records of KMC services.



Page 31

10. PERFORMANCE ASSESSMENT FOR ZANZIBAR

10.1. BASIC INFORMATION ON ZANZIBAR KMC UNIT

The KMC services in Zanzibar are provided at the Mwembeladu Maternity Hospital. The


supervision visit:

Table 10-1: Basic Information on Zanzibar KMC Unit

Item Description


Mwembeladu Maternity Hospital


Hospital

Location Urban West Region, Urban West district

Ownership

Government



20 health workers


unit/ward

4


training

2


During the project period, two (2) external supervision exercises were done on 23rd March

2012 (during year 4) and on 06th November 2012 (during year 5). No supervision visits were

done in Zanzibar during year 1, 2 and 3.

10.2.1. First Supervision Visit on 23rd March 2012

The assessment results during the first visit ranked the KMC performance at 85%.

Generally, the performance of the KMC unit was good. The staff working at the site were

committed to their work and were taking necessary steps to ensure that awareness of KMC

method is made to the public. The KMC staff had drawn pictures of men and women

carrying babies in KMC position. However, the cleanliness of the room was not up to the

required standards. Relatives should not be allowed to sleep on beds prepared for mothers

and their babies. The temperature of the room was OK and the KMC staff were advised to

ensure that the heater is in good condition and ready to be used when the temperature fell to

below normal range.

10.2.2. Second Supervision Visit on 06th November 2012

The assessment results showed that the Zanzibar KMC had maintained the same standards.

Performance was good and remained at 85%. Only a few challenges listed below were

observed which could be easily addressed for better performance.

The level of education of mothers was low and took them time to understand KMC key components

There was no system for tracking mothers lost to follow up especially those living far from the town



Page 32

Immunization was denied

The hospital was not providing food for patients. This led to some of the mothers requesting for early discharge while some absconded from the hospital


Based on the two visits, the Zanzibar KMC unit scored an average performance of 85% as


Table 10-2: Average Performance for Zanzibar KMC Unit



2 KMC services are institutionalized in the facility 3 3 3.0

3 The provider prepares the mother and the baby for KMC 3 3 3.0

4 The provider ensures that the baby is fed correctly 3 3 3.0

5 The provider monitors the baby receiving KMC correctly 3 3 3.0

6 Infection prevention and control practices are adhered 2 2 2.0


2 2 2.0


3 3 3.0

9 The baby receives regular follow ups 3 3 3.0

10 KMC readmission criteria 3 3 3.0

11 Discontinuation of babies from KMC 3 3 3.0





10.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE ZANZIBAR FACILITY





Table 10-3: Information on Pre-term and LBW Babies in Zanzibar Facility


Percentage Remarks


544 N/A











Page 33






6 N/A

From the results above, all babies admitted in the KMC unit were accounted for. This shows

that the site keeps proper records of KMC services. Out of all babies admitted at the facility,

82% are Pre-term and LBW. This shows that there is high demand of KMC services in

Zanzibar. The number of babies who die at the KMC unit is also high, 72 out of 431 (17%).

There is need to establish and address the causes of death for babies under KMC.



Page 34

11. PERFORMANCE ASSESSMENT FOR KAGERA

11.1. BASIC INFORMATION ON KAGERA KMC UNIT

The KMC services in Kagera region are provided at the Bukoba Regional Referral Hospital.

The basic information about the facility is as shown in the table below as per records of the

last supervision visit:

Table 11-1: Basic Information on Kagera KMC Unit

Item Description


Bukoba Regional Referral Hospital


Hospital

Location Kagera Region, Bukoba Urban

Ownership

Government



24: 20 Health workers, 2 master trainers, 2 master

supervisors


unit/ward

2


training

2


During the project period, two (2) external supervision exercises were done on 14th May


done in Kagera during year 1, 2 and 3.


The supervision team observed that the performance of the site was generally good. Both

KMC types were practiced, i.e. at the site (continuous KMC) and at post natal ward

(intermittent KMC). However, at the time of assessment there were no babies at the KMC

room and thus not all performance areas were assessed. Only 7 performance areas were

assessed and rated. For details of performance areas assessed refer to Table 11-3 in sub

section 11.3.3. The overall performance was rated at 71%.

Some challenges were also observed and suggestions for action discussed as shown in the

table below:

Table 11-2: Kagera Challenges and Agreed Action

Challenge Action

No funds for sensitization of the community

HMT to mobilize funds to support sensitization

activities Lack of secretarial and communication services

HMT to ensure that secretarial and

communication services are consistently availed

Internal supportive supervision was not being done by the HMT as per the KMC guidelines

HMT and KMC team to ensure that internal

supportive supervision is on monthly basis



Page 35

There was no system to track mothers who are lost to follow up

HMT and KMC team to establish a system to track

mothers who are lost to follow up

Space limitation HMT to allocate a spacious room for implementing

continuous KMC

Understaffing of skilled nursing cadre Matron to allocate staff who will manage KMC site

on monthly basis

Hospital not providing food as a result mothers with no relative support abscond from the hospital

HMT to recognize and integrate KMC services

with other hospital services


During the second visit, the overall assessment improved to 87% compared to the previous

assessment of 71% recorded in the first visit. The performance of the KMC unit was

generally good despite the outstanding challenges that still remained unsolved. The HMT

appreciated the entire assessment procedure which they described as participatory,

supportive and educative. The HMT committed to addressing the outstanding challenges as

follows:

Space limitation: The HMT has already put into its hospital plans to provide

enough space for KMC services

Mothers lost to follow up: The HMT informed the supervision team that

discharged LBW babies will be handed over to respective districts for follow

up.

- Focal person to link with DRCHCO

- Need to convince the council to build waiting mothers home for KMC to

stay

Shortage of trained staff in KMC room and lack of commitment to implement

quality KMC services: The HMT will identify the root causes and solve the

problem

The community not yet sensitized on KMC services: The RRCHCO and

Regional social welfare officer will be involved and the HMT will check the

possibility of providing financial support.

Hospital not providing food and as a result mothers with no relative support

abscond from the hospital: The HMT admitted that they had financial

constraints and would liaise with the social welfare for support.



Page 36


Based on the two visits, the Kagera KMC unit scored an average performance of 85% as


Table 11-3: Average Performance for Kagera KMC Unit




3 The provider prepares the mother and the baby for KMC Not rated 3 3.0

4 The provider ensures that the baby is fed correctly Not rated 3 3.0


6 Infection prevention and control practices are adhered Not rated 2 2.0


Not rated 3 3.0


2 3 2.5

9 The baby receives regular follow ups Not rated 3 3.0

10 KMC readmission criteria Not rated 3 3.0






11.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE KAGERA FACILITY





Table 11-4: Information on Pre-term and LBW Babies in Kagera Facility


Percentage Remarks


491 N/A














5 N/A



Page 37


and babies lost to follow exceeds the number of babies admitted at the KMC site by 55

(30%). This shows that the site does not keep proper records of KMC services. Babies lost

to follow up are also significant (30%) and measures need to be put in place to ensure that

the number is reduced or eliminated completely. There is demand for KMC services in the

region as 66% of new born babies were Pre-term and LBW.



Page 38

12. PERFORMANCE ASSESSMENT FOR MWANZA REGION

12.1. BASIC INFORMATION ON MWANZA KMC UNIT

The KMC services in Mwanza region are provided at the Sekotoure Regional Hospital. The


supervision visit:

Table 12-1: Basic Information on Mwanza KMC Unit

Item Description


Sekotoure Regional Hospital


Hospital

Location Mwanza Region, Mwanza Urban

Ownership

Government



22: 20 general KMC and 2 master trainers


unit/ward

3 trained nurses


training

3


During the project period, two (2) external supervision exercises were done on 02nd May


done in Mwanza during year 1, 2 and 3.

12.2.1. First Supervision Visit on 02nd May 2012

Generally, the performance of the KMC unit at Mwanza is good with an assessed

performance of 85%. The hospital management has provided great support to KMC services

by allocating at least two trained personnel to work at KMC unit. KMC staff are very

committed to ensure the KMC concept at the hospital is a success.

Some challenges were also observed and suggestions for action discussed as shown in the

table below:

Table 12-2: Mwanza Challenges and Agreed Action

Challenge Action

Space limitation: The room was found to be small and not conducive for KMC services. It didn’t meet KMC standards

MO/C to release conference room

Poor security of KMC room which makes it not possible to keep equipment e.g heater, weighing scale etc

A bigger and lockable room is required. Proper hand over of equipment to be exercised by staff during change of shifts

Service providers in KMC room: Only 2 trained staff on KMC. The KMC operation is affected when one staff is off-duty

More staff to be trained and allocated to the unit



Page 39

Those trained not ready to work in KMC room. MO/C already informed but not ready to take action.


To make a follow up of mothers who default KMC visit is difficult; no means for communication

Concept notes & proposals required for awareness creation

Poor customer care given to mothers, especially when focal person is off-duty.


Hospital not providing quality food – this result to some mothers absconding from KMC.

HMT to integrate KMC services into other hospital services

Lack of stationery

HMT to integrate KMC services into other hospital services

Community awareness and involvement

Concept notes & proposals required for awareness creation


During the second visit, the overall assessment remained at 85% as was assessed in the

first visit. The performance of the KMC unit was generally good despite the outstanding

challenges that still remained unsolved. The HMT appreciated the entire assessment

procedure which they described as participatory, supportive and educative. The HMT

committed to addressing the outstanding challenges as follows:

Lack of food services for patients at the KMC unit: The HMT confirmed that at the time of assessment, the hospital could not afford food for patients due to budget constraints. The HMT agreed to discuss the issue and increase the budget accordingly.

Mothers lost to follow up: The matron agreed to take short term measures of using the hospital mobile telephone to trace mothers.

Stationery not sufficient: The KMC staff were requested to present their stationery requirement to hospital administration for consideration

Internal referral of sick babies: The MOI/C agreed to strengthen the coordination process


Based on the two visits, the Mwanza KMC unit scored an average performance of 85% as


Table 12-3: Average Performance for Mwanza KMC Unit









3 3 3.0


3 3 3.0





Page 40




Total Score 33.0 33.0 33.0


12.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE MWANZA FACILITY



admitted in the KMC ward, 251 (71%) were discharged successfully, 43 (12%) died, 9 (3%)

absconded while 30 (8%) were lost to follow up as shown in the table below.

Table 12-4: Information on Newborns including Pre-term and LBW Babies in Mwanza

Facility


Percentage Remarks


852 N/A














7 N/A

From the results above, 20(6%) of the babies admitted at the KMC site were not accounted

for. This shows that the site does not keep proper records of KMC services. There is

demand for KMC services in the region as 660 (77%) of new born babies were Pre-term and

LBW.



Page 41

13. PERFORMANCE ASSESSMENT FOR MARA REGION

13.1. BASIC INFORMATION ON MARA KMC UNIT

The KMC services in Mara region are provided at the Musoma Regional Hospital. The basic


supervision visit:

Table 13-1: Basic Information on Mara KMC Unit

Item Description


Musoma Regional Hospital


Hospital

Location Musoma Region, Musoma Urban

Ownership

Government



22: 18 general KMC, 2 master trainers and 2 master

supervisors


unit/ward

2


training

3


During the project period, two (2) external supervision exercises were done on 07th May


done in Mara during year 1, 2 and 3.


Assessment results show that the performance of the site is poor. The site’s performance

was rated at 59%. At the time of assessment, there were no babies in the KMC room and

some performances areas were not assessed. Only 9 performance areas were assessed

and rated. For details of performance areas assessed refer to Table 13-3 in sub section

13.3.3. Other major findings were:

Recording keeping of KMC services is not consistently and correctly done.

Action plan developed by the HMT during formal training in August 2011 had not

been implemented.

Despite having trained master supervisors, no internal supportive supervision was

done during the reporting period.

There is a gap between HMT and KMC Unit, which has been impacting negatively on

the KMC service.

Other challenges identified and proposed actions are as shown in the table below:



Page 42

Table 13-2: Mara Challenges and Agreed Action

Challenge Action

The physical setting was not conducive for implementing KMC services. It does not provide enough warmth

The HMT need to make room modifications to

make it suitable for KMC services

Other trained staff were not willing to work in KMC room except the focal person

Matron to allocate staff who will manage KMC site

on monthly basis

The community was not well sensitized on KMC services

HMT in collaboration with MoHSW to mobilize

funds to support sensitization activities

The setting does not provide enough security for storage of equipments

HMT to allocate space for storage of KMC

equipments

Lack of secretarial and communication services

Secretarial and communication services should

consistently be available and KMC services to be

recognized and integrated with other services

Internal supportive supervision was not being done by the HMT

HMT team to conduct internal supportive

supervision on monthly basis

There was no system to track mothers who are lost to follow up

HMT to establish a system to track mothers who

are lost to follow up


According to the assessment done using the checklist, the site recorded an improved

performance of 72%, up from the previously recorded 59% in the first visit. However, the

supervision team was in the opinion that the 72% assessment as per the checklist did not

reflect the actual situation of the site. The supervision team reports that the performance of

the site was not pleasing despite having master trainers and supervisors in place. Two

supportive supervision exercises were done, one external and one internal and still no

remarkable improvement was noticed. Several challenges identified and discussed on how

to address them in the previous visit still remain unsolved:

The present setting of the room was not conducive for implementing KMC services.

In the previous visit, the HMT agreed to modify it but nothing had been done during

the second visit. In addition, the room has no furniture e.g. lockers, beds and

cupboards etc

The hospital does not provide food for patients and as result, mothers request for

premature discharge

Cleanliness of feeding utensils is not guaranteed

Information from the MoHSW does not reach the end users on time. e.g. KMC staff

had no official information of the present visit


Based on the two visits, the Mara KMC unit scored an average performance of 69% as




Page 43

Table 13-3: Average Performance for Mara KMC Unit




3 The provider prepares the mother and the baby for KMC N/A 2 2.0




N/A 2 2.0


N/A 3 3.0


3 3 3.0


10 KMC readmission criteria N/A 3 3.0






13.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE MARA FACILITY




absconded while 15(15%) were lost to follow up as shown in the table below.

Table 13-4: Information on Pre-term and LBW Babies in Mara Facility


Percentage Remarks


302 N/A














4 N/A

From the results above, all the babies admitted at the KMC site were accounted for. This

shows that the site keeps proper records of KMC services. There is demand for KMC



Page 44

services in the region as 181 (60%) of newborn babies were LBW babies. The number of

babies who died is also significant (18 out of 98, 18%) and the causes of death at the site

should be established and addressed to avoid further deaths.



Page 45

14. PERFORMANCE ASSESSMENT FOR SHINYANGA REGION

14.1. BASIC INFORMATION ON SHINYANGA KMC UNIT

The KMC services in Shinyanga region are provided at the Shinyanga Regional Referral

Hospital. The basic information about the facility is as shown in the table below as per

records of the last supervision visit:

Table 14-1: Basic Information on Shinyanga KMC Unit

Item Description


Shinyanga Regional Referral Hospital


Hospital

Location Shinyanga Region, Shinyanga Urban

Ownership

Government



22: 20 health workers and 2 master trainers


unit/ward

3


training

1


During the project period, two (2) external supervision exercises were done on 21st June

2012 (during year 4) and on 09th January 2013 (during year 5). No supervision visits were

done in Shinyanga during year 1, 2 and 3.

14.2.1. First Supervision Visit on 21st June 2012

At the time of assessment, some performances areas were not assessed due to lack of

information. Only 9 performance areas were assessed and rated. For details of performance

areas assessed refer to Table 14-4 in sub section 14.3.3. Assessment results for assessed

areas were very good with the site’s performance rated at 93%. The demand for KMC

services is high and the available space is not enough. Documentation of KMC services is

also not properly done. There is a need for the hospital team of supervisors to conduct

regular internal supervision and document the process and results. Other challenges

identified and proposed actions are as shown in the table below:

Table 14-2: Shinyanga Challenges and Agreed Action

Challenge Action

Mothers are not fed sufficient food with required nutrients by their relatives. As a result, they demand discharge before their babies meet criteria for discharge

The Hospital to ensure that there is a continuous

education on KMC services to parents during

visits to RCH clinics

Space limitation HMT to see the possibility of expansion of the

existing room (renovation)



Page 46

No link between the hospital and health facilities located at the community

HMT to look for the possibility of scaling KMC

services to district level (train health workers)

No patients cupboards for storage of mother's belongings and for babies

HMT to ensure availability of a cupboard for

storing mothers belongings and this can be placed

outside the room

14.2.2. Second Supervision Visit on 09th January 2013

During the second visit, all performance areas were assessed and the performance rated at

82%. Previous reported challenges in the first visit still remained unsolved. The available

KMC space was still small and could not meet the demand. Counseling was not properly

done, resulting to poor adherence to KMC practice.

Regarding outstanding challenges affecting KMC services at the hospital, the HMT reacted

as follows:

Table 14-3: Shinyanga HMT reaction to Outstanding Challenges

Challenge Reaction

Space limitation Extension of the ward will be discussed during

HMT meeting with RAS. The room will be

relocated to a new hospital building (Long term

plan) Poor cleaning and storage of feeding

cups

Utensils required to be purchased

No patients cupboards for storage of

mother's belongings and for babies

The cupboards will be purchased at the end of

January 2013

Poor allocation of staff trained on KMC

Re-allocation of staff to be done by the hospital

matron.

There is no system in place to sensitize

the community on KMC concept

Mothers will be sensitized during ANC visits -

Regional RCHCO. RHMT to support Master

TOTs of KMC to sensitize the community.


Based on the two visits, the Shinyanga KMC unit scored an average performance of 83% as


Table 14-4: Average Performance for Shinyanga KMC Unit




3 The provider prepares the mother and the baby for KMC Not rated 3 3.0

4 The provider ensures that the baby is fed correctly Not rated 2 2.0


6 Infection prevention and control practices are adhered Not rated 2 2.0


Not rated 1 1.0


3 3 3.0



Page 47








14.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE SHINYANGA FACILITY




absconded while 10 (3%) were lost to follow up as shown in the table below.

Table 14-5: Information on Newborns and LBW Babies in Shinyanga Facility


Percentage Remarks


773 N/A













6 N/A

From the results above, 47(13%) of the babies admitted at the KMC site were not accounted

for. This shows that the site does not keep proper records of KMC services. There is

demand for KMC services in the region as 689 (89%) of new born babies were LBW babies.

Only 3 (1%) of babies admitted in the unit died. This shows that the Shinyanga unit has done

well in ensuring that deaths of babies undergoing KMC are minimized or avoided.



Page 48

15. PERFORMANCE ASSESSMENT FOR SINGIDA REGION

15.1. BASIC INFORMATION ON SINGIDA KMC UNIT

The KMC services in Singida region are provided at the Singida Regional Hospital. The


supervision visit:

Table 15-1: Basic Information on Singida KMC Unit

Item Description


Singida Regional Hospital


Hospital

Location Singida Region, Singida Urban

Ownership

Government



24: 20 health workers, 2 KMC trainers, 2 KMC

supervisors


unit/ward

2 permanent staff


training

4


During the project period, two (2) external supervision exercises were done on 14th June

2012 (during year 4) and on 13th December 2012 (during year 5). No supervision visits were

done in Singida during year 1, 2 and 3.

15.2.1. First Supervision Visit on 14th June 2012

The performance of KMC services at Singida was evaluated as very good with a

performance score of 93%. The site excelled in documentation, record keeping and

reporting. Three performance areas related to mother and baby were not rated because at

the time of assessment, there was no LWB baby at the unit. For details of performance

areas not assessed refer to Table 15-3 in sub section 15.3.3.

A few challenges were identified and proposed actions were discussed as shown in the table

below:

Table 15-2: Singida Challenges and Agreed Action

Challenge Action

Space limitation The room is on temporary basis, KMC services

will be shifted to a spacious room in the new

building

Lack of stationery and support for

secretarial services

KMC focal person to be provided with a ream of

A4 papers for official use and be supported for

secretarial services and communication with

mothers lost to follow up



Page 49

The number of staff who received formal

KMC training is inadequate

KMC master trainer to ensure that KMC topics are

included in continuing education sessions

Negative attitude among few trained staff

towards implementation of KMC services

HMT needs to look for best approach (es) that can

be used in addressing issues of attitude and

behavior towards patient’s care

Hospital stopped providing food to

patients including mothers at KMC site

coming from remote areas

HMT to re-consider provision of food to mothers at

KMC with no relative support (especially those

coming from remote areas).

15.2.2. Second Supervision Visit on 13th December 2012

During the second visit, most of the gaps and challenges observed in the previous

supervision visit had been addressed. Only a few like inadequate space for KMC services

needed long term solutions. The performance of the KMC unit was generally very good,

scoring a 100% mark. The HMT appreciated the entire assessment exercise which they

described as participatory, supportive and educative. The HMT committed to addressing the

outstanding challenges as follows:

As a temporary measure, KMC services would be shifted to a spacious room in the

new building to provide more space

One ream of paper would be provided to the KMC unit after every two months to

solve the problem of inadequate stationery for KMC services

KMC focal person would continue with the current arrangement of joining RHMT

during their routine supervision to community level to ensure increased community

awareness on KMC services


Based on the two visits, the Singida KMC unit scored an average performance of 97% as


Table 15-3: Average Performance for Singida KMC Unit




3 The provider prepares the mother and the baby for KMC N/A 3 3.0



6 Infection prevention and control practices are adhered N/A 3 3.0


3 3 3.0


3 3 3.0



11 Discontinuation of babies from KMC N/A 3 3.0





Page 50



15.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE SINGIDA FACILITY


postnatal wards. Out of this, 345 (42%) were admitted in the KMC ward as shown in the

table below.

Table 15-4: Information on Newborns and Pre-term and LBW Babies in Singida Facility


Percentage Remarks


813 N/A














3 N/A


and babies lost to follow exceeds the number of babies admitted at the KMC site by 9 (2%).


KMC services in the region as 695 (85%) of new born babies were LBW babies. If the data

on deaths is correct, only 5 (1%) of babies admitted in the unit died. This shows that the

Singida unit has done well in ensuring that deaths of babies undergoing KMC are minimized

or avoided.



Page 51

16. PERFORMANCE ASSESSMENT FOR DODOMA REGION

16.1. BASIC INFORMATION ON DODOMA KMC UNIT

The KMC services in Dodoma region are provided at the Dodoma Regional Hospital. The


supervision visit:

Table 16-1: Basic Information on Dodoma KMC Unit

Item Description


Dodoma Regional Hospital


Hospital

Location Dodoma Region, Dodoma Urban

Ownership

Government



28: 25 health workers, 1 KMC trainer and 2 KMC

supervisors


unit/ward

1


training

4


During the project period, two (2) external supervision exercises were done on 11th June

2012 (during year 4) and on 11th December 2012 (during year 5). No supervision visits were

done in Dodoma during year 1, 2 and 3.

16.2.1. First Supervision Visit on 11th June 2012

The performance of the KMC unit at Dodoma during the first supervision visit was evaluated

as very good with a performance score of 94%. The KMC team was noted to be utilizing the

knowledge and skills they acquired through a formal training conducted in April 2011. The

team at Dodoma is a visionary one, using art (posters) to create awareness on the KMC

concept to the public. The Dodoma hospital management has included most of the issues

related to care of pre-term babies in agenda items of different forums held in the hospital.

e.g. maternal and peri-natal auditing meetings held on quarterly basis.

A few challenges were identified and proposed actions were discussed between the HMT

and the supervision team as shown in the table below:



Page 52

Table 16-2: Dodoma Challenges and Agreed Action

Challenge Action

Available space cannot meet demand for

KMC services from neigbouring areas in

the region

HMT to discuss with RHMT to initiate and

establish a functional system that would help

other health facilities (district hospitals) to initiate

KMC services.

The location of the toilets in the present

infrastructure is not user friendly,

mothers cannot use the toilets at night

because the toilets are outside of the

ward

This will be solved once the site is moved to the

new maternity wing

Due to unreliable electricity supply, the

use of oxygen concentrator is limited and

this poses a risk to babies who need

artificial support

HMT to ensure that oxygen flow meters and nasal

proms are available at KMC site for use when the

power is off. There is also a need to have an

additional oxygen concentrator to meet the

demand

Mothers lost to follow up due to various

reasons

HMT with support from RHMT to propose a

workable system that could be used to track

mothers for follow up

16.2.2. Second Supervision Visit on 11th December 2012

During the second visit, most of the gaps and challenges observed in the previous

supervision visit had been addressed while some needed long term solutions. The

performance of the KMC unit was generally very good, scoring a 95% mark. The KMC team

was properly utilizing all their knowledge and skills from formal training to ensure success of

the KMC concept at the hospital.


Based on the two visits, the Dodoma KMC unit scored an average performance of 95% as


Table 16-3: Average Performance for Dodoma KMC Unit









3 3 3.0


3 3 3.0



11 Discontinuation of babies from KMC N/A 3 3.0



Page 53





16.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE DODOMA FACILITY



table below.

Table 16-4: Information on Newborns including Pre-term and LBW Babies in Dodoma

Facility


Percentage Remarks


2,190 N/A














8 N/A


and babies lost to follow exceeds the number of babies admitted at the KMC site by 61 (9%).


KMC services in the region as almost half 1,183 (54%) of newborn babies were LBW .



Page 54

17. PERFORMANCE ASSESSMENT FOR TANGA REGION

17.1. BASIC INFORMATION ON TANGA KMC UNIT

The KMC services in Tanga region are provided at the Bombo Regional Hospital. The basic


supervision visit:

Table 17-1: Basic Information on Tanga KMC Unit

Item Description


Bombo Regional Hospital


Hospital

Location Tanga Region, Tanga Urban

Ownership

Government



22: 20 health workers received formal KMC training, 2

KMC master trainers


unit/ward

5 nurses in the maternity ward working on rotational basis. 2 are trained in KMC and 3 are not


training

2


During the project period, two (2) external supervision exercises were done on 30th March

2012 (during year 4) and on 29th January 2013 (during year 5). No supervision visits were

done in Tanga during year 1, 2 and 3.


The performance of the KMC unit at Tanga during the first supervision visit was evaluated as

very good with a performance score of 92%. The KMC team was noted to be very committed

to their work and was making efforts ensure that everyone visiting the site got a message on

the KMC concept. It was also observed that there was a lot of support from the hospital

management team. Out of all the 19 KMC sites, Tanga is the only site where KMC services

have been institutionalized. There is a lot of sharing and learning through continuous

education, a session held every month and includes all staff, medical and nurses students

including Intern doctors.

17.2.2. Second Supervision Visit on 29th January 2013

During the second visit, it was assessed that the performance was still good although it had

dropped to 82% from the previous 92% assessed during the first visit. Despite the drop in

assessed performance, the HMT was still very supportive in delivering KMC services. The

hospital team appreciated the assessment exercise which they termed as participatory,

supportive and helpful. The assessment exercise made them gain knowledge and skills on

KMC services which they would use to improve areas where gaps were identified. Several

gaps were identified that led to the drop, most of which were associated with inadequate

knowledge and skills of health workers to provide quality KMC services. These gaps are

listed below:



Page 55

Inadequate space for KMC services.

Low understanding level of some mothers resulting to failure in adhering to

KMC practice

Shortage of trained personnel for KMC unit

Lack of utensils for cleaning and storing feeding cups.

Lack of essential equipments/supplies for use in KMC. e.g. oxygen

concentrator, digital weighing scale were out of order, electric kettle, gowns,

shoes and basins

It was unfortunate that at the time of concluding the assessment, the MOI/C and the HMT

were not available for feedback and discussion on the way forward to address the identified

gaps. The MOI/C and the HMT were in a series of meetings with the Regional

Commissioner.


Based on the two visits, the Tanga KMC unit scored an average performance of 87% as


Table 17-2: Average Performance for Tanga KMC Unit









2 3 2.5


3 2 2.5








17.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE TANGA FACILITY



table below.



Page 56

Table 17-3: Information on Newborns including Pre-term and LBW Babies in Tanga

Facility


Percentage Remarks


1,908 N/A














3 N/A

There is demand for KMC services in the region as 1,217 (64%) of new born babies were

LBW babies. Only 1 (negligible %) of babies admitted in the unit died. This shows that the

Tanga unit has done well in ensuring that deaths of babies undergoing KMC are minimized

or avoided.



Page 57

18. PERFORMANCE ASSESSMENT FOR MBEYA REGION

18.1. BASIC INFORMATION ON MBEYA KMC UNIT

The KMC services in Mbeya region are provided at the Ruanda Health Centre. The basic


supervision visit:

Table 18-1: Basic Information on Mbeya KMC Unit

Item Description


Ruanda Health Centre


Health Centre

Location Mbeya Region, Mbeya Urban

Ownership

Government



9


unit/ward

3 (working on rotational basis)


training

3


During the project period, three (3) external supervision exercises were done on 09th

September 2011 (during year 3), 21st August 2012 (during year 4) and on 18th February

2013 (during year 5). No supervision visits were done in Mbeya during year 1 and 2.

18.2.1. First Supervision Visit on 09th September 2011

At the time of visit, only three months had elapsed since the KMC unit at Ruanda Health

Centre began its operations. Ruanda’s assessed performance was very good with a score of

92%. The Ruanda management team was demonstrating great support and all staff at the

maternity ward and at the KMC unit were highly motivated. However, the facility faces

shortage of skilled staff and resources for effective service delivery. Coaching session on

weak areas was being done and the staff requested for continued support in training of more

staff and more medicals supplies e.g. clean gloves, additional bed nets, lockers for mothers

with babies at the KMC site. The supervising team advised the KMC staff to share some of

the challenges with their management team for support and to continue educating other staff

on advantages of KMC services.

18.2.2. Second Supervision Visit on 21st August 2012

During the second visit, the performance had improved from 92% to 97%. There was a lot of

peer learning among staff which led to the improved performance. The management team of

the health facility committed themselves to work on areas that were found with weaknesses.

A few challenges existed concerning lack of stationery supplies and facilitation on

communication. It was reported that Municipal Medical Officer of Health had already

instructed heads of department to select a team of 6 members who would present their

departmental problems to the Municipal authority for action.



Page 58

18.2.3. Third Supervision Visit on 18th February 2013

Performance assessment during the third supervision visit showed that the KMC services

were performing well at a score of 95%. Most of the gaps identified in previous visits had

already been addressed. The unit was warm and very clean, all four beds were occupied,

and services were being offered as required. The management team appreciated that the

exercise was very participatory and have promised to work further on areas that were still

found with some weaknesses.


Based on the three visits, the Mbeya KMC unit scored an average performance of 95% as


Table 18-2: Average Performance for Mbeya KMC Unit


2nd Visit

3rd Visit

Average




3 3 3 3.0



3 3 3 3.0



3 3 3 3.0


3 3 3 3.0







Percentage 92% 97% 95% 95%

18.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE MBEYA FACILITY

During the project period, no data was available on the number of new born babies admitted

at the neonatal and/or the postnatal wards. There were 199 LBW babies admitted in the

KMC ward, and out of this, 143 (72%) were discharged, 2 (1%) died, none absconded and 2

(1%) were lost to follow up as shown in the table below.



Page 59

Table 18-3: Information on Newborns including Pre-term and LBW Babies in Mbeya

Facility


Percentage

Remarks


0 N/A




199 N/A

Total LBW babies 256 N/A









4 N/A

Only 2 (1%) of babies admitted in the unit died. This shows that the unit has done well in

ensuring that deaths of babies undergoing KMC are minimized or avoided. However, from

the above results, 52 (26%) of babies admitted at the KMC site were not accounted for. This

shows that the site does not keep proper records of KMC services.



Page 60

19. PERFORMANCE ASSESSMENT FOR RUKWA REGION

19.1. BASIC INFORMATION ON RUKWA KMC UNIT The KMC services in Rukwa region are provided at the Sumbawanga Regional Hospital. The


supervision visit:

Table 19-1: Basic Information on Sumbawanga KMC Unit

Item Description


Sumbawanga Regional Hospital


Hospital

Location Rukwa Region, Sumbawanga Urban

Ownership

Government



22: 20 health workers, 2 master trainers)


unit/ward

3 (one in each shift)


training

3

19.2. ASSESSMENT FROM SUPERVISION VISITS During the project period, two (2) external supervision exercises were done on 23rd August

2012 (during year 4), and on 20th February 2013 (during year 5). No supervision visits were

done in Sumbawanga during year 1, 2 and 3.

19.2.1. First Supervision Visit on 23rd August 2012

The assessed performance of Sumbawanga KMC services was very good with a score of

92%. The supervision team observed that the spirit of team work was high and the hospital

team appreciated the assessment exercise which helped them to improve their knowledge

and skills on KMC.

Despite the good performance, a few gaps were identified and solutions were discussed

between the supervision team and the HMT as follows:

Table 19-2: Sumbawanga Challenges and Agreed Action

Challenge Action

Inadequate sockets in KMC room Installation of additional sockets to be solved jointly with RHMT. The MOI/C to provide a extension cable as a temporary measure

Inadequate toilets and bathrooms for KMC mothers – There is only one toilet and a shower for 15 patients

Long term measure required by modification of the room or relocate KMC services to another room



Page 61

Inadequate support on secretarial and communication services from HMT

To be discussed during the therapeutic committee meeting which is a forum to discuss and solve hospital matters

There is no system to track mothers who are lost to follow up due to distance

To be discussed during the therapeutic committee meeting which is a forum to discuss and solve hospital matters

Lack of awareness on KMC concept at community as far as peripheral level

Issue to be discussed this with the RHMT

19.2.2. Second Supervision Visit on 20th February 2013

In the second assessment, the performance dropped from the previously recorded 92% in

the first assessment to 72%. General performance was not pleasing and through a question

and answer session, it was observed that the level of understanding of KMC guidelines by

KMC team was still low. This resulted to failure by the team to provide quality KMC services

in areas of pre and post counseling, documentation of the neonates’ information, criteria for

admission, discharge and follow up not adhered to and posters with advocacy messages

related to the three KMC elements (positioning, support and feeding) not utilized.

Communication barrier still existed because some of the responsible key staff were not

aware of the visit despite notification letters sent by the MoHSW to the RMO about the visit.

The KMC room was spacious and well ventilated but needed an additional heater due to the

cold weather. The room thermometer was not in place to measure room temperature.

Gaps previously identified in the first visit still persisted. There were inadequate toilets and

bathrooms for KMC mothers, there was no system to track mothers who were lost to follow

up and there was no awareness on KMC concept at community level. During the feedback

meeting, the Deputy MOI/C urged every member of staff especially those who received

formal KMC training to play their role in supporting provision of quality KMC services. The

KMC focal person was requested to improve the overall management of the KMC unit with

special focus on documentation of neonates’ information. The staff working at the unit were

requested to be pro active in seeking assistance from the KMC master supervisors or master

trainers.


Based on the two visits, the Rukwa KMC unit scored an average performance of 85% as


Table 19-2: Average Performance for Rukwa KMC Unit









3 1 2.0


3 3 3.0




Page 62





Total Score 36.0 30.0 33.0


19.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE RUKWA FACILITY

During the project period, there were 233 LBW babies admitted in the KMC ward, and out of

this, 163 (70%) were discharged, 33 (14%) died, 4 (2%) absconded and 22 (9%) were lost to

follow up as shown in the table below.

Table 19-3: Information on Newborns including Pre-term and LBW Babies in Rukwa

Facility


Percentage

Remarks


366 N/A














4 N/A

However, from the above results, 11 (5%) of babies admitted at the KMC ward were not

accounted for. The sum of LBW babies admitted at the KMC ward and the

neonatal/postnatal wards also exceeds the total number of newborns admitted at the

hospital. This shows that the site does not keep proper records of KMC services. The

number of children who died is also quite significant and the KMC staff together with the

hospital management should establish the causes and address them to stop further deaths.



Page 63

20. PERFORMANCE ASSESSMENT FOR KILIMANJARO REGION

20.1. BASIC INFORMATION ON KILIMANJARO KMC UNIT The KMC services in Kilimanjaro region are provided at the Mawenzi Regional Hospital. The


supervision visit:

Table 20-1: Basic Information on Kilimanjaro KMC Unit

Item Description


Mawenzi Regional Hospital


Hospital

Location Kilimanjaro Region, Moshi Urban

Ownership

Government



31: 29 health workers had formal KMC training, 2

master trainers)


unit/ward

3


training

2

20.2. ASSESSMENT FROM SUPERVISION VISITS During the project period, two (2) external supportive supervision visits were done on 26th

July 2012 (during year 4), and on 21st May 2013 (during year 5). No supervision visits were

done in Kilimanjaro during year 1, 2 and 3.

20.2.1. First Supervision Visit on 26th July 2012

Although the physical outlook of the KMC unit was very good with adequate space, well

arrangement and clean, the assessed performance was not good. The KMC site scored 58%

with many gaps being identified. The KMC staff seemed not to have adequate knowledge

and skills on provision of quality KMC services. Other challenges identified are:

Mothers lost to follow up due to lack of tracking system

Poor cleaning and storage of feeding cups

Electrical wall sockets were not enough

The hospital does not provide food for patients. As a result mothers admitted

at the KMC unit tend to request for early discharge.

Staff allocated to work in the KMC unit are not trained

The hospital management promised to provide a TV for recreation but no

follow up was done.

20.2.2. Second Supervision Visit on 21st May 2013

In the second visit, the physical set up and general cleanliness of the unit was still very good

and the unit met all the requirements for provision of KMC services. The unit had adequate

space, good ventilation and was well arranged. The assessed performance improved from



Page 64

58% to 79%. Despite the improvement, new gaps were identified with the older challenges

remaining unattended.

New gaps

Frequent change of staff in the KMC room caused inconsistency in managing the unit

and provision of quality care to the babies.

It was also noted that the discharge criteria was not well known to health providers

working in the unit, because most of the babies were unnecessarily kept in the ward

while mothers could have been discharged to continue with KMC at home after

proper counseling.

Staff working in the unit did not bother to check and ensure equipments in the room

were in good working condition. The oxygen concentrator had never been used

because of a fault and no efforts were made to repair it.

Older Challenges

Mothers lost to follow up due to lack of tracking system

Poor cleaning and storage of feeding cups

Electrical extension cable to connect heaters not available

Internal KMC supervision is not conducted as required

Hospital management team promised to provide a TV for recreation but no follow up

was done.


Based on the two visits, the Kilimanjaro KMC unit scored an average performance of 68% as


Table 20-2: Average Performance for Kilimanjaro KMC Unit









1 3 2.0


2 2 2.0


10 KMC readmission criteria N/A 1 1.0




Total Score 21.0 31.0 26.5




Page 65

20.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE KILIMANJARO FACILITY


this, 129(77%) were discharged, 7(4%) died, 1(1%) was absconded and 1(1%) was lost to

follow as shown in the table below.

Table 20-3: Information on Newborns including Pre-term and LBW Babies in

Kilimanjaro Facility


Percentage Remarks


330 N/A














9 N/A

However, from the above results, 29 (17%) of babies admitted at the KMC ward were not

accounted for. The sum of LBW babies admitted at the KMC ward and the

neonatal/postnatal wards also exceeds the total number of newborns admitted at the

hospital. This shows that the site does not keep proper records of KMC services.



Page 66

21. PERFORMANCE ASSESSMENT FOR DAR ES SALAAM REGION

21.1. BASIC INFORMATION ON DAR ES SALAAM KMC UNIT The KMC services in Dar es Salaam region are provided at the Mbagala Rangi Tatu Health

Centre. The basic information about the facility is as shown in the table below as per records

of the last supervision visit:

Table 21-1: Basic Information on Dar es Salaam KMC Unit

Item Description


Mbagala Rangi Tatu Health Centre


Health Centre

Location Dar es salaam Region, Temeke Municipality

Ownership

Government



6: 4 trained under MAISHA and 2 health workers by

CCBRT


unit/ward

3 (working on a rotation basis)


training

2

21.2. ASSESSMENT FROM SUPERVISION VISITS During the project period, only one (1) external supervision exercise was done on 01st

November 2012 (during year 5). No supervision visits were done in Dar es Salaam during

year 1, 2, 3 and 4.

The assessed performance was very good with the KMC unit scoring 95%. The assessment

exercise was carried out in a participatory and supportive manner. The spirit of team work

was high at the site. A better performance would have been achieved if more support from

the health centre management was extended to the KMC team.

A number of challenges were also identified as follows:

Inadequate toilets and bathrooms for KMC mothers. There is only one toilet and a

shower for 8 patients

Mothers demand early discharge due to lack of food

Mothers look untidy with casual clothes; they need 3 uniforms per patient and

napkins

No clothe line within the laundry, the lining space is outside

There is shortage of staff.

The is lack of awareness on KMC concept at the local level in the community

Since only one external supervision exercise was done, it can be assumed that the average

performance for the unit is 95% as shown in the table below:



Page 67

Table 21-2: Performance Assessment for Dar es Salaam KMC Unit


1 KMC physical setting 3

2 KMC services are institutionalized in the facility 3

3 The provider prepares the mother and the baby for KMC 3

4 The provider ensures that the baby is fed correctly 3

5 The provider monitors the baby receiving KMC correctly 3

6 Infection prevention and control practices are adhered 3

7 The mother of the baby receiving KMC and her family are supported 3

8 The baby is discharged from the facility according to guidelines 3

9 The baby receives regular follow ups 3

10 KMC readmission criteria 3

11 Discontinuation of babies from KMC 3

12 KMC services are known to the community 2

13 Monitoring and evaluation of KMC services 2

Total Score 37.0

Percentage 95%

21.3. ANALYSIS OF PRE-TERM AND LBW BABIES AT THE DAR ES SALAAM FACILITY


this, 63 (76%) were discharged, 2 (2%) died, 6 (7%) absconded and 15 (18%) were lost to

follow up as shown in the table below.

Table 21-3: Information on LBW Babies in Dar es Salaam Facility


Percentage Remarks


1 N/A




83

Total LBW babies 138









6 N/A

From the above results, 3 (3%) of babies admitted at the KMC ward were not accounted for.

The sum of LBW babies admitted at the KMC ward and the neonatal/postnatal wards also

exceeds the total number of newborns admitted at the hospital. This shows that the site does

not keep proper records of KMC services or the data has not been updated.



Page 68

22. GENERAL PERFORMANCE OF THE 19 HEALTH FACILITIES PROVIDING

KMC

22.1. RANKING OF REGIONAL PERFORMANCES

According to the assessment criteria provided by the MOHSW, the best performing region in

KMC services provision is Ruvuma, where services are offered at the Songea Regional

Hospital. During the external supervision visits, the unit was assessed to have performed

very well in almost all performance areas and scored an average mark of 99%. The results

from the assessment checklist are in agreement with the observations made by the

supervision team on the ground. The supervision team described the Songea KMC unit as

“a role model and a centre of excellence”.

Singida region ranked second with an average score of 97%. Dodoma, Mbeya, and Dar es

Salaam are in third position with an average score of 95%. The worst performing region is

Kigoma which has an average score of 49%. During the external supervision visits at

Maweni Regional Hospital in Kigoma where the KMC services are offered, it was established

that there was no specific space allocated for implementing KMC services and the staff did

not have adequate knowledge on KMC services. During the last visit to the hospital, the

performance had worsened to 8%. Ranking for the rest of the regions is shown in the table

below:

Table 22-1: Overall ranking of health facility performances in the 19 selected regions

Region Average Score Percentage Remarks Ranking

Ruvuma 38.5 99% Very Good 1

Singida 38.0 97% Very Good 2

Dodoma 37.0 95% Very Good 3

Mbeya 37.0 95% Very Good 3

Dar es salaam 37.0 95% Very Good 3

Mtwara 36.5 94% Very Good 6

Tanga 34.0 87% Very Good 6

Iringa 33.0 85% Very Good 8

Zanzibar 33.0 85% Very Good 8

Kagera 33.0 85% Very Good 8

Mwanza 33.0 85% Very Good 8

Rukwa 33.0 85% Very Good 8

Shinyanga 32.5 83% Very Good 13

Arusha 29.3 75% Very Good 16

Mara 27.0 69% Very Good 15

Kilimanjaro 26.5 68% Very Good 16

Manyara 24.7 63% Good 17

Tabora 23.3 60% Good 18

Kigoma 19.0 49% Good 19



Page 69

22.2. PERFORMANCE PER GRADING CRITERIA

According to the assessment criteria provided by the MOHSW, 16 regions (84%) performed

“very good”, 3 (16%) performed “good” while none performed “weak” as shown in the

summarized assessment table below:

Table 22-2: Performance per Grading Criteria

Assessment Score No. of Regions Percentage

Very Good 67-100% 16 84%

Good 33-66% 3 16%

Weak Below 33% 0 0%



Page 70

23. PERFORMANCE PER ASSESSMENT AREAS

23.1. KMC SITE PHYSICAL SETTING

Fifteen (15) regions (79%) scored “very good”, 3 regions (16%) scored “good” and 1 region

(5%) scored “weak” in the KMC site physical setting. From these results, most of the sites

(79%) have properly set KMC units. More details on performance of this area are shown in

the table below:

Table 23-1: Assessment of KMC Sites Physical Setting

Assessment Average Score

No. of Regions

% of Regions

Names of Regions

Very Good 3 15 79% Ruvuma,Zanzibar,Mara,Shinyanga, Singida,Dodoma, Kilimanjaro, Dar es Salaam, Manyara, Mbeya, Mtwara, Iringa,Kagera, Mwanza, Rukwa

Good 2 3 16% Tabora, Kigoma, Tanga

Weak 1 1 5% Arusha

Total 19 100%

23.2. KMC SERVICES ARE INSTITUTIONALIZED IN THE FACILITY

Eleven (11) regions (58%) scored “very good”, 7 regions (37%) scored “good” and 1 region

scored “weak” in institutionalizing KMC services in their health facilities. From these results,

almost half of the sites (58%) have integrated KMC operations as part of regular hospital

services. More details on performance of this area are shown in the table below:

Table 23-2: Assessment of Institutionalizing KMC Services in Facility


No. of Regions

% of Regions

Names of Regions

Very Good 3 11 58% Ruvuma,Zanzibar, Singida, Dodoma,Dar es Salaam, Mbeya, Mtwara, Iringa,Kagera, Rukwa, Tanga

Good 2 7 37% Mara,Shinyanga, Kilimanjaro, Manyara, Mwanza, Arusha, Tabora

Weak 1 1 5% Kigoma

Total 19 100%

23.3. THE PROVIDER PREPARES THE MOTHER AND BABY FOR KMC

Sixteen (16) regions (84%) scored “very good”, 3 regions (16%) scored “good” and no region

scored “weak” in preparing the mother and baby for KMC services. These results show that

in most sites (84%) mothers and babies were being prepared as required before

implementing the KMC services. More details on performance of this area are shown in the

table below:

Table 23-3: Assessment in Preparing the Mother and Baby for KMC


No. of Regions

% of Regions

Names of Regions

Very Good 3 16 84% Ruvuma, Zanzibar, Singida, Dodoma, Dar es Salaam, Mbeya, Mtwara, Iringa, Kagera, Rukwa, Tanga, Shinyanga, Kilimanjaro, Mwanza, Arusha, Tabora

Good 2 3 16% Kigoma, Mara, Manyara,

Weak 1 0 0% Nil

Total 19 100%



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23.4. THE PROVIDER ENSURES THAT THE BABY IS FED CORRECTLY

Fourteen (14) regions (74%) scored “very good”, 4 regions (21%) scored “good” and 1

region (5%) scored “weak” in ensuring that the baby is fed correctly. These results show that

in many sites (74%) babies were being fed correctly. More details on performance of this

area are shown in the table below:

Table 23-4: Assessment in Ensuring that the Baby is Fed Correctly


No. of Regions

% of Regions

Names of Regions

Very Good 3 14 74% Ruvuma, Zanzibar, Singida, Dodoma, Dar es Salaam, Mbeya, Mtwara, Iringa,Kagera, Rukwa, Tanga, Kilimanjaro, Mwanza, Arusha

Good 2 4 21% Tabora, Manyara, Shinyanga, Kigoma,

Weak 1 1 5% Mara

Total 19 100%

23.5. THE PROVIDER MONITORS THE BABY RECEIVING KMC CORRECTLY

Twelve (12) regions (63%) scored “very good”, 4 regions (21%) scored “good” and 3 region

(16%) scored “weak” in ensuring that the health provider monitors the baby receiving KMC

correctly. From these results, it can be concluded that in many sites (63%), the KMC staff

were monitoring babies to ensure that they were receiving KMC correctly. More details on

performance of this area are shown in the table below:

Table 23-5: Assessment in Provider Monitoring the Baby receive KMC Correctly

23.6. INFECTION PREVENTION AND CONTROL PRACTICES ARE ADHERED

Eleven (11) regions (58%) scored “very good”, 8 regions (42%) scored “good” and no region

scored “weak” in adhering to infection prevention and control practices. From these results, it

can be concluded that in almost half of the sites (58%), measures and guidelines set to

prevent and control infections were being followed. More details on performance of this area

are shown in the table below:

Table 23-6: Assessment in Adherence to Infection Prevention and Control Practices


No. of Regions

% of Regions

Names of Regions

Very Good 3 11 58% Ruvuma, Singida,Dodoma, Dar es Salaam, Mbeya, Mtwara, Iringa, Mwanza, Arusha, Rukwa, Kilimanjaro


No. of Regions

% of Regions

Names of Regions

Very Good 3 12 63% Ruvuma, Zanzibar, Singida,Dodoma, Dar es Salaam, Mbeya, Mtwara, Iringa,Kagera, Tanga, Mwanza, Shinyanga,

Good 2 4 21% Arusha, Manyara, Rukwa, Kilimanjaro

Weak 1 3 16% Mara, Tabora, Kigoma,

Total 19 100%



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Good 2 8 42% Manyara, Mara, Tabora, Kigoma, Zanzibar,Kagera,Shinyanga,Tanga

Weak 1 0 0%

Total 19 100%

23.7. THE MOTHER & HER FAMILY ARE SUPPORTED

Twelve (12) regions (63%) scored “very good”, 6 regions (32%) scored “good” and 1 region

(5%) scored “weak” in the performance area of mother and her family being supported by

health providers in carrying out KMC. From these results, it can be concluded that in many

sites (63%), the mothers and their families were being supported by the KMC staff to carry

out KMC services properly. More details on performance of this area are shown in the table

below:

Table 23-7: Assessment on the Mother and her Family being supported


No. of Regions

% of Regions

Names of Regions

Very Good 3 12 63% Ruvuma, Singida, Dodoma, Dar es Salaam, Mbeya, Mtwara, Iringa, Mwanza, Mara, Tabora, Kagera,Tanga

Good 2 6 32% Manyara, Arusha, Kigoma, Rukwa, Zanzibar, Kilimanjaro

Weak 1 1 5% Shinyanga

Total 19 100%

23.8. THE BABY IS DISCHARGED ACCORDING TO GUIDELINES

Fifteen (15) regions (79%) scored “very good”, 4 regions (21%) scored “good” and no region

scored “weak” in discharging a baby from the KMC facility according to guidelines. From

these results, it can be concluded that many sites (79%) were discharging babies from KMC

units as required. More details on performance of this area are shown in the table below:

Table 23-8: Assessment in discharging the Baby from the Facility


No. of Regions

% of Regions

Names of Regions

Very Good 3 15 79% Ruvuma, Zanzibar, Singida, Dodoma, Dar es Salaam, Mbeya, Mtwara, Iringa, Kagera, Rukwa, Tanga, Mwanza, Arusha, Shinyanga, Mara,

Good 2 4 21% Tabora, Kigoma, Kilimanjaro, Manyara,

Weak 1 0 0% Nil

Total 19 100%

23.9. THE BABY RECEIVES REGULAR FOLLOW UPS

Fifteen (15) regions (79%) scored “very good”, 3 regions (16%) scored “good” and 1 region

(5%) scored “weak” in discharging a baby from the KMC facility according to guidelines.

From these results, it can be concluded that many sites (79%) were making regular follow



Page 73

ups to babies as required. More details on performance of this area are shown in the table

below:

Table 23-9: Assessment on Regular Follow Up to Babies


No. of Regions

% of Regions

Names of Regions

Very Good 3 15 79% Ruvuma, Zanzibar, Singida, Dodoma, Dar es Salaam, Mbeya, Mtwara, Iringa, Kagera, Rukwa, Tanga, Mwanza, Arusha, Shinyanga, Mara,

Good 2 3 16% Kigoma, Kilimanjaro, Manyara,

Weak 1 1 5% Tabora

Total 19 100%

23.10. KMC RE-ADMISSION CRITERIA FOLLOWED


regions (16%) scored “weak” in following the criteria set for re-admitting babies into the KMC

facility. From these results, it can be concluded that many sites (74%) were re-admitting

babies into the KMC units as required. More details on performance of this area are shown

in the table below:

Table 23-10: Assessment on Re-admission Criteria


No. of Regions

% of Regions

Names of Regions

Very Good 3 14 74% Ruvuma, Zanzibar, Singida, Dodoma, Dar es Salaam, Mbeya, Mtwara, Iringa, Kagera, Rukwa, Tanga, Mwanza, Shinyanga, Mara,

Good 2 2 11% Tabora, Arusha

Weak 1 3 16% Kigoma, Kilimanjaro, Manyara,

Total 19 100%

23.11. DISCONTINUATION OF BABIES FROM KMC


region (5%) scored “weak” in following the guidelines for discontinuing babies from the KMC

facility. From these results, it can be concluded that many sites (74%) were discontinuing

babies from the KMC units as required. More details on performance of this area are shown

in the table below:

Table 23-11: Assessment on Discontinuation of Babies


No. of Regions

% of Regions

Names of Regions

Very Good 3 14 74% Ruvuma, Zanzibar, Singida, Dodoma, Dar es Salaam, Mbeya, Mtwara, Kagera, Rukwa, Tanga, Mwanza, Shinyanga, Mara,Kilimanjaro

Good 2 4 21% Kigoma, Manyara, Arusha, Iringa

Weak 1 1 5% Tabora

Total 19 100%



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23.12. KMC SERVICES ARE KNOWN TO THE COMMUNITY

Only 3 regions (16%) scored “very good”, 6 regions (32%) scored “good” and 10 regions

(53%) scored “weak” in creating awareness on KMC services to the neighbouring local

communities and the public at large. From these results, it can be deduced that the KMC

concept is not well known to the local communities. Almost half of the sites (53%) scored

less than 33% as shown in the table below:

Table 23-11: Assessment on Awareness of KMC Services


No. of Regions

% of Regions

Names of Regions

Very Good 3 3 16% Ruvuma, Singida, Tanga

Good 2 6 32% Dar es Salaam, Mbeya, Mtwara, Rukwa, Mwanza, Shinyanga

Weak 1 10 53% Tabora, Arusha, Zanzibar, Dodoma, Kagera, Iringa, Mara, Kilimanjaro, Manyara, Kigoma

Total 19 100%

23.13. MONITORING AND EVALUATION OF KMC SERVICES

Only 7 regions (37%) scored “very good”, 10 regions (53%) scored “good” and 2 regions

(11%) scored “weak” in the area of Monitoring and Evaluation (M&E) of KMC services. From

these results, it can be deduced that many KMC sites do not know the importance of M&E.

There is also a possibility that they do not have skills and knowledge to conduct M&E. More

details of performance in this area are shown in the table below:

Table 23-11: Assessment on Monitoring and Evaluation


No. of Regions

% of Regions

Names of Regions

Very Good 3 7 37% Ruvuma, Singida, Tanga, Mara, Shinyanga, Mtwara, Dodoma

Good 2 10 53% Dar es Salaam, Mbeya, Rukwa, Mwanza, Arusha, Zanzibar, Kagera, Iringa, Kilimanjaro, Manyara

Weak 1 2 11% Kigoma, Tabora

Total 19 100%



Page 75

24. ANALYSIS OF DOCUMENTED DATA

24.1. BEST PERFORMERS IN DATA DOCUMENTATION

It is only in 4 regions (21%) where data on LBW babies admitted in the KMC sites is properly

recorded. These regions are Manyara, Zanzibar, Musoma and Tanga. The rest of the 15

regions (79%) did not record data properly and there is a lot of inconsistency in data

reporting. In the 15 sites, some LBW babies admitted for KMC services were not accounted

for, while in some cases the sum of babies discharged, those that died and those that were

lost to follow up exceeded the total number of babies admitted. It is reported that this

inconsistency was caused by some LBW babies who were gaining weight slowly and the

reporting format did not have a place to report this. The LBW babies slowly gaining weight

were thus reported in the following months.

24.2. ADMISSION OF LBW BABIES AT KMC SITES

During the project period, Iringa region topped in admission of LBW babies for KMC services.

Out of the 8,119 babies admitted, 856(11%) were from Iringa region. The lowest admission

was from Dar es Salaam and Mara (1% each). Admissions for other regions are as shown in

the table below:

Table 24-1: Admission of LBW Babies at KMC Sites

Region Total number of babies admitted in KMC units

% admitted Region Total number of babies admitted in KMC units

% admitted

Iringa 856 11% Shinyanga 361 4%

Mtwara 841 10% Mwanza 353 4%

Tabora 803 10% Singida 345 4%

Ruvuma 768 9% Rukwa 233 3%

Dodoma 654 8% Mbeya 199 2%

Arusha 528 7% Kagera 182 2%

Tanga 460 6% Kilimanjaro 167 2%

Zanzibar 431 5% Mara 98 1%

Kigoma 380 5% Dar es Salaam

83 1%

Manyara 377 5% Total 8,119 100%

24.3. BABIES DISCHARGED FROM KMC WARD

During the project period, Manyara region discharged the highest number of babies (97% of

total LBW babies they had admitted). The region that recorded the lowest discharge was

Mara that discharged 59% of the LBW babies they had admitted. In all the regions, 6,407

(79%) of all LBW babies admitted into the KMC sites were discharged. Discharge rates for

other regions are as shown in the table below:



Page 76

Table 24-2: Discharge of Babies from KMC Sites

Region LBW babies admitted to KMC units

Total Discharged from KMC

% discharged

Region LBW babies admitted to KMC units

Total Discharged from KMC

% discharged

Singida 345 348 N/A Arusha 528 407 77%

Manyara 377 366 97% Dar es Salaam

83 63 76%

Dodoma 654 617 94% Mbeya 199 143 72%

Tanga 460 430 93% Mwanza 353 251 71%

Kagera 182 153 84% Rukwa 233 163 70%

Shinyanga 361 300 83% Tabora 803 557 69%

Zanzibar 431 346 80% Ruvuma 768 530 69%

Kigoma 380 303 80% Iringa 856 581 68%

Mtwara 841 662 79% Mara 98 58 59%

Kilimanjaro 167 129 77% Total 8,119 6,407 79%

24.4. DEATH OF BABIES AT KMC SITES

During KMC implementation period, Mara and Zanzibar regions had the highest number of

babies succumbing to death. The two regions recorded 18% and 17% respectively, of the

total number of Pre-term and LBW babies they had admitted in their sites. Regions that

recorded low number of deaths are Tanga (negligible %), Shinyanga (1%), Mbeya (1%),

Arusha (1%), Manyara (1%) and Singida(1%). A total of 8,119 LBW babies were admitted in

all sites and out of this, 446 (5%) died. It is reported that the deaths were related to asphyxia

due to suffocation as a result of poor feeding, pneumonia hypothermia, infections, congenital

malaria, hypoglycemia and bleeding from mouth and nose. Death rates for the other regions

are as shown in the table below:

Table 24-3: Death of Babies at KMC Sites

Region Total number of babies admitted in KMC units

Babies who died in KMC units

% of babies who died in KMC units

Mara 98 18 18%

Zanzibar 431 72 17%

Rukwa 233 33 14%

Mwanza 353 43 12%

Kagera 182 17 9%

Ruvuma 768 61 8%

Kigoma 380 24 6%

Tabora 803 47 6%

Dodoma 654 33 5%

Mtwara 841 39 5%

Kilimanjaro 167 7 4%

Iringa 856 28 3%

Dar es Salaam 83 2 2%



Page 77

Singida 345 5 1%

Manyara 377 5 1%

Arusha 528 6 1%

Mbeya 199 2 1%

Shinyanga 361 3 1%

Tanga 460 1 0%

Total 8,119 446 5%

24.5. MOTHERS ABSCONDED WITH THEIR PRE-TERM AND LBW BABIES FROM KMC

WARD

During the project period Singida, Manyara and Mbeya KMC sites did not have any cases of

absconded babies. Mara, Kagera and Dar es Salaam sites had the highest number of

absconded babies equal to 7% of all the babies they had admitted. In all the regions, 173

(2%) of all LBW babies admitted into the KMC sites were absconded. Rates for absconded

babies for other regions are as shown in the table below:

Table 24-4: Abscondees at KMC Sites

Regions Babies admitted to KMC

Abscondees

% absconded Regions Babies admitted to KMC

Aabscondees

% absconded

Singida 345 0 0% Tanga 460 9 2%

Manyara 377 0 0% Mwanza 353 9 3%

Mbeya 199 0 0% Ruvuma 768 22 3%

Shinyanga 361 1 0% Tabora 803 30 4%

Iringa 856 4 0% Kigoma 380 15 4%

Kilimanjaro 167 1 1% Mtwara 841 34 4%

Dodoma 654 6 1% Mara 98 7 7%

Arusha 528 5 1% Kagera 182 13 7%

Zanzibar 431 7 2% Dar es Salaam

83 6 7%

Rukwa 233 4 2% Total 8,119 173 2%

24.6. BABIES LOST TO FOLLOW UP

During the project period Singida, Manyara Kagera, Dodoma and Zanzibar KMC sites had the

lowest number of babies lost to follow (1% and below) of the LBW babies they had admitted

into their facilities. Tabora had the highest number of babies lost to follow, recording 54(30%)

of all the babies they had admitted into the KMC unit. In all the regions, 440(5%) of all LBW

babies admitted into the KMC sites were lost to follow. Rates for babies lost to follow for other

regions are as shown in the table below:

Table 24-5: Babies Lost to Follow up


Babies lost to follow

% lost to follow up


Babies lost to follow up

% lost to follow

Singida 345 1 0% Kigoma 460 25 5%

Mara 528 2 0% Tanga 353 30 8%

Kagera 167 1 1% Rukwa 654 59 9%

Dodoma 431 4 1% Mtwara 233 22 9%

Zanzibar 199 2 1% Kilimanjaro 768 75 10%

Ruvuma 841 14 2% Mbeya 380 48 13%



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Iringa 377 8 2% Mwanza 98 15 15%

Arusha 361 10 3% Dar es Salaam

83 15 18%

Manyara 856 25 3% Tabora 182 54 30%

Shinyanga 803 30 4% Total 8,119 440 5%

24.7. PERIOD OF STAY OF BABIES AT KMC SITES

The recorded average period of stay of babies at the KMC sites that occurs frequently (21%

of the regions) is 4 days. The shortest stay is 3 days (16% of the regions) and the longest

stay is 13 days (5%) of the regions. Other periods of stay are as shown in the table below:

Table 24-2: Period of Stay of Babies at KMC Sites

Recorded Average Period of Stay at KMC sites (days)

Regions with Corresponding Periods of Stay as in Column (1)

Frequency % Frequency

1 None 0 0

2 None 0 0

3 Singida, Manyara, Tanga 3 16%

4 Kigoma, Mbeya, Mara, Rukwa 4 21%

5 Tabora, Mtwara, Kagera 3 16%

6 Zanzibar, Shinyanga,Dar es Salaam

3 16%

7 Iringa, Ruvuma, Mwanza 3 16%

8 Dodoma 1 5%

9 Kilimanjaro 1 5%

10 None 0 0

11 None 0 0

12 None 0 0

13 Arusha 1 5%

14 None 0 0

15 None 0 0

Over 15 None 0 0

19 100%



Page 79

25. CONCLUSION AND RECOMMENDATIONS

25.1. CONCLUSION

The initiative by MAISHA Programme to implement the KMC project in collaboration with SC

is quite commendable and has received great support from all stakeholders; the MOHSW,

respective health facilities and the beneficiaries. The project has seen many lives of babies

saved under facility based KMC and many service providers have been trained on the

provision of KMC services to make the KMC concept sustainable. The supervision exercises

have largely been described as participatory, supportive and educative by the service

providers.

Generally the performance of the 19 sites is good, although there are similar and recurrent

challenges in many of the sites. If these challenges are addressed in time, better services will

be realized. According to the assessment criteria in the monitoring tool, 16 regions (84%)

performed “very good”, 3 (16%) performed “good” while none performed “weak”.

The demand for KMC services in the 19 sites is quite high. Many of the neonates admitted to

the health facilities were pre-term with LBW. For instance, in Manyara region, 97% of all

newborns were pre-term and LBW. Many other regions had LBW babies accounting for more

than 50% of all newborn babies admitted in the respective health facilities.

25.2. RECOMMENDATIONS

From the analysis of the supportive supervision reports and the consolidated data on pre-

term and LBW babies at all the 19 sites, the following recommendations were made:

The grading system for awarding of marks in the assessment criteria for

performance areas prepared by the MOHSW (monitoring checklist) for use during

supervision exercises should be reviewed. Some supervision reports indicate that

the marks scored by some sites do not reflect the actual situation on the ground.

The sites scored high marks than they deserved. These reports are those for

Iringa (3rd visit), Kigoma (2nd visit), Kagera (1st visit) and Musoma (1st visit). The

current grading system has 3 categories with intervals of 33 marks, which

apparently lumps many sites in one category. The number of categories could be

increased to lower the interval of marks in order to segregate the sites accordingly

as per actual performance.

More efforts are needed to increase awareness on KMC services. In many sites, it

is evident that the neighbouring local communities are not aware of these

services. Only 3 regions (16%) scored “very good” in creating awareness on KMC

services.

More efforts are also needed in educating and training of staff working in KMC

units on M&E. From the analysis of performance reports, only 7 regions (37%)

scored “very good” in the area of M&E of KMC services.

There is need to sensitize the KMC staff and the HMT to keep proper records of

KMC services and also improve the reporting format. The data provided in many



Page 80

sites is inconsistent. Some LBW babies admitted for KMC services were not

accounted for, while in some sites the sum of babies discharged, those that died

and those that were lost to follow up exceeded the total number of babies

admitted.

Other areas that need joint efforts between the MOHSW and the HMTs are

provision of adequate space for KMC services (in sites where space is a problem)

and provision of food to admitted mothers to address the problem of mothers

seeking early discharge.

Sample Checklist 1

ANNEX 1: SAMPLE CHECKLIST

Background information

1. Read this checklist carefully before filling 2. Write the answer by putting a tick in the corresponding box or on the space

provided 3. Provide an appropriate feedback if required

Name of Health Facility: ......................................................................................... Number of health providers trained on KMC in the health facility: ..................................

o Working in KMC Unit/ward: .......................................................................

o How many were followed up after training: ................................................

District: ................................................................................................................................ Region: ................................................................................................................................ Type of Health Facility

Hospital

Health Centre Ownership

o Government o Faith based o Private o Others (explain): ________________________________________

Location: Urban: Rural:

Names of Supervisors:

1. ............................................................................................................................. 2. ............................................................................................................................. 3. .............................................................................................................................. 4. ............................................................................................................................... 5........................................................................................................................ 6............................................................................................................................. 7..............................................................................................................................

Supervision date: ........................................................................................................

Sample Checklist 2

KMC CHECKLIST

PERFORMANCE AREAS VERIFICATION/CRITERIA YES NO GRADE REMARKS

KMC PHYSICAL SETTING

Check KMC room/space if;

Is close to maternity ward and neonatal nursery

Have adequate space.

Have adequate ventilation.

Have power supply with socket (at least one socket for every 2 bed

Have adequate shower and toilet facilities (atleast one toilet/shower for every ten beds).

Percentage:

KMC SERVICES ARE

INSTITUTIONALIZED IN THE

FACILITY

Interview with other providers in the hospital if:

Hospital management and staff are aware of KMC service at the facility

maternity/newborn ward staff oriented to KMC

Resources identified and allocated to KMC:

o Trained service providers

o KMC equipment and supplies (look on the inventory)

KMC guideline is available in the unit

KMC job aids are available in the unit (Counseling cards, rediness for discharge, dangers signs, feeding charts, etc)

Percentage:

THE PROVIDER PREPARES THE

MOTHER AND BABY FOR KMC

Observe if the provider prepares for KMC by:

Explains the concept and benefits of KMC to the mother

Demonstrates how it is done

Ensures all stable babies less than 2500g are provided with KMC

Prepares and places baby in correct KMC position

o Baby dressed only in nappy, cap and socks

o Places baby between mother’s breasts

o Secures baby skin to skin on mothers chest with

Sample Checklist 3

appropriate wrapper/local cloth

Instruct mother / care giver the following:

o Wear open front top

o Keep baby in upright position

o Ensure continuous skin to skin contact (may be intermittent when appropriate to circumstances)

o Sleep in slanted half sitting position to maintain baby upright

Percentage:

THE PROVIDER ENSURES THAT

THE BABY IS FED CORRECTLY

Observe if the provider

Ensures babies are fed as per schedule(look on the feeding charts)

Ensure proper attachment during breastfeeding.

Babies are breastfed or fed EBM by cup/NGT or Fed alternatively by cup or NGT

Encourages exclusive breastfeeding for 6 months

Calculates feeds using guidelines for volume of feeds required per day based on age and weight of baby

Percentage:

THE PROVIDER MONITORS THE

BABY RECEIVING KMC

CORRECTLY

Observe if the provider:

Ensures baby is in continuous skin to skin position

Registers baby and records details in KMC register

Monitors and records vital signs every 12 hours, and more frequently when required (temperature, respiration).

Records feeds given as per schedule

Takes baby’s daily weight to monitor growth

Percentage:

INFECTION PREVENTION AND

CONTROL

Observe if the mother/Care taker:

Washes her hands with clean running water and soap

o Before and after feeding baby

Sample Checklist 4

o Before and after changing nappies

o After attending toilet

Cleans all cups and feeding utensils before and after use and stored in covered clean container.

Ensures baby’s umbilical cord is kept clean and dry

Takes bath appropriately and puts on clean cloths

Cleans/wipes baby daily with warm water and soft cloths (“head to toe”)

Ensures baby wears clean and dry nappies

Percentage:

THE MOTHER AND HER FAMILY

ARE SUPPORTED


Integrates another family member into care, as appropriate

Discusses and helps mother with any problems related to KMC positioning

Discusses and helps mother with feeding and care of the baby

Encourages mother to continue KMC

Encourages mother/family member to express concerns and ask questions

Percentage: 80%

THE BABY IS DISCHARGED

FROM THE FACILITY

ACCORDING TO GUIDELINES

o Baby has gained weight and has a minimum weight of 1500g

o Continous weight gain of at least 15 gm per day for three consecutive days.

o KMC position is well tolerated by baby and mother

o Has no danger sign

o Mother is confident and competent breast feeding and/or feeding expressed breast milk

o Mother accepts KMC method and is willing to continue with KMC at home

Sample Checklist 5

Mother can get support from relatives at home and she is willing to come back for followup visits

Percentage:

PERFORMANCE AREAS VERIFICATION/CRITERIA YES NO GRADE REMARKS

THE BABY RECEIVES REGULAR

FOLLOW UPS


Ensures follow up of babies after discharge is done o Every week for babies weighing between 1500g, and 1800g o Every 2 weeks for babies weighing >1800g o For any other medical indication

Ensures baby is immunized according to EPI guidelines

Weighs the baby

take history from mother/guardian If KMC is continuing at home, continuous or intermitent and duration of skin-to-skin contact

How baby is feeding or being fed

If baby has any danger signs and continues educating the mother on danger signs

If baby is showing any signs of intolerance to KMC (baby too active and uncomfortable in KMC position)

Performs a physical assessment of the baby

Discusses experiences/problems mother may have in continuing KMC and gives support

Praise the mother/care taker and encourages mother/family to continue KMC as needed

Schedules the next visit as relevant x

KMC RE-ADMISSION CRITERIA

Check KMC records for last 3-6 months: check 3 cases of re-admision

Readmits baby to health facility (according to national guidelines):if baby has:

Sample Checklist 6

Gained less than 15g/day in two consecutive follow up visits

lost weight

danger signs or is sick

If mother not continuing KMC as required and baby is less than 2500gm

Percentage:

DISCONTINUATION OF BABIES

FROM KMC

Observe or interview if the provider discontinues baby from KMC when:

Baby reaches weight of 2500g

Baby does not tolerate KMC (becomes very active and is uncomfortable in KMC position)

Percentage: 100%

KMC SERVICES ARE KNOWN TO

THE COMMUNITY

Assess for community awareness on KMC if;

The family members are aware of KMCservices.

Community leaders/influential people are aware of KMC

Services.

Community health workers, CORPs (TBAs,CDBs and VHWs)

are aware of KMC services.

Percentage:

MONITORING AND EVALUATION

Observe KMC Monitoring and Evaluation Tools

KMC register available and properly filled

Previous KMC Supervision Report available

Supervision checklist for KMCis available

KMC hospital summary sheets available and properly filled

KMC referral letter available and properly filled

KMC Daily score sheet available and properly filled

KMC Follow up visit records available and properly filled

Monitoring Process

Monthly martenity/ neonatal meeting is done

KMC agenda are included in montjly martenity and neonatal meetings

Sample Checklist 7

KMC monthly Reports available

Percentage: 40%

Sample Checklist 8

SUMMARY OF KMC SUPORTIVE SUPERVISION FACILITY: …………………………………………………………………………..

PERFOMANCE AREA SCORE REMARKS(Very Good, Good, Poor)

KMC PHYSICAL SETTING

KMC SERVICES ARE INSTITUTIONALIZED IN THE FACILITY

THE PROVIDER PREPARES THE MOTHER AND BABY FOR KMC

THE PROVIDER ENSURES THAT THE BABY IS FED CORRECTLY

THE PROVIDER MONITORS THE BABY RECEIVING KMC CORRECTLY

INFECTION PREVENTION AND CONTROL PRACTICES ARE ADHERED

THE MOTHER OF THE BABY RECEIVING KMC AND HER FAMILY ARE SUPPORTED

THE BABY IS DISCHARGED FROM THE FACILITY ACCORDING TO GUIDELINES

THE BABY RECEIVES REGULAR FOLLOW UPS

KMC READMISSION CRITERIA

DISCONTINUATION OF BABIES FROM KMC

KMC SERVICES ARE KNOWN TO THE COMMUNITY

MONITORING AND EVALUATION OF KMC SERVICES

TOTAL SCORE X

PERCENTAGE: (X/39 x100) =

analysis of performance and utilization … · analysis of performance and utilization of kangaroo...

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