FURTHER ANALYSIS OF THE COST ESTIMATE STRATEGY FIELD TEST IN KENYA

MARGARET MAKUMI

TAKEMI FELLOW 2003/2004 HARVARD SCHOOL OF PUBLIC HEALTH

JUNE, 2004

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TABLE OF CONTENTS Acknowledgment-------------------------------------------------------------------------------------v List of Abbreviations--------------------------------------------------------------------------------vi Executive Summary--------------------------------------------------------------------------------vii Chapter 1----------------------------------------------------------------------------------------------1 Introduction-------------------------------------------------------------------------------------------1 Background-------------------------------------------------------------------------------------------1 Cost Estimate Strategy (CE) -----------------------------------------------------------------------1 The CES Field Test in Kenya----------------------------------------------------------------------2 Setting up the CES in Kenya-----------------------------------------------------------------------3

a) Selection of important RH conditions and services------------------------------------3 b) Determination of local prices--------------------------------------------------------------4

Rational for further analysis of the CES field test Data----------------------------------------4 The Research Questions-----------------------------------------------------------------------------5 Chapter 2----------------------------------------------------------------------------------------------7 Methodology------------------------------------------------------------------------------------------7 Study Sites and Sources of Data and Methods---------------------------------------------------7 Data Collection and Analysis-----------------------------------------------------------------------8 Chapter 3----------------------------------------------------------------------------------------------9 Part 1---------------------------------------------------------------------------------------------------9 Availability of RH basic commodities and equipments at sample facilities---------------------------------------------------------------------------------------9 a) Availability of Key Commodities from the Districts’ Perspective------------------------10

i) Amoxicillin-----------------------------------------------------------------------------10 ii) Normal Saline--------------------------------------------------------------------------11 iii) Non Sterile Gloves and Sterile Gloves---------------------------------------------12

b) Equipment----------------------------------------------------------------------------------------13 i) Basic Equipment for MCH Clinics--------------------------------------------------------13 ii) Basic equipment for Labor, Delivery and Postnatal Care-----------------------------14 iii) Equipment Required for Caesarian Section Services---------------------------------15

Practice Patterns-------------------------------------------------------------------------------------16 Health Care Provider Reported Practices--------------------------------------------------------16

i) Provision of Iron Sulphate to ANC Mothers--------------------------------------17 ii) Use of Ergometrine in Normal Delivery-------------------------------------------18 iii) Use of Amoxicillin in the Management of Puerperal Sepsis--------------------18

Mothers’ Interviews--------------------------------------------------------------------------------19 Estimated Cost for Treating RH Conditions and Equipments--------------------------------20 Part 11------------------------------------------------------------------------------------------------21 Nature of Service Packages------------------------------------------------------------------------21 Usefulness of the Costing Model-----------------------------------------------------------------21 Location of Services Provided--------------------------------------------------------------------22 Reported Treatment Patterns----------------------------------------------------------------------22 Chapter 4---------------------------------------------------------------------------------------------23 Conclusions and Recommendations--------------------------------------------------------------23

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Reference--------------------------------------------------------------------------------------------24 Annex 1----------------------------------------------------------------------------------------------26 Selected RH Conditions and Services Annex 2----------------------------------------------------------------------------------------------27 Tables on Availability of RH Commodities at Sampled Health Facilities Annex 3----------------------------------------------------------------------------------------------34 Tables on Availability of RH Equipment at Sampled Health Facilities Annex 4----------------------------------------------------------------------------------------------41 Tables on Health Care Workers Self Reporting Practice Patterns Annex 5-------------------------------------------------------------------------------58 Survey Forms

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TABLES AND FIGURES

Figure 1 Availability of Amoxicillin---------------------------------------------------------11 Figure 2 Availability of Normal Saline at All Facilities-----------------------------------12 Table 1 Availability of Non Sterile Gloves and Sterile Gloves----------------------------------------------------------------------------------13 Figure 3 Availability of Suction Machine at all Facilities---------------------------------15 Figure 4 Availability of Lagenback Retractors in all Facilities-------------------------------------------------------------------------------16 Table 2 Health Care Workers recommending use of Iron Sulphate to ANC Mothers-----------------------------------------------------17 Table 3 Use of Ergometrine by all health care workers in Normal Delivery------------------------------------------------------------------18 Table 4 Use of Amoxicillin by all Health Care Workers for Management of Puerperal Sepsis--------------------------------------------------19 Table 5 ANC mothers Given Iron Sulphate------------------------------------------------19 Table 6 Postnatal Mothers Who Bought Non Sterile Gloves----------------------------------------------------------------------------------20 Table 2.1 Facilities where RH Commodities were Available------------------------------------------------------------------------------28 Table 2.2 Availability of Selected Key Commodities at Sample Facilities in the Sampled Districts-------------------------------------------------30 Table 3.1 Availability of Essential Basic MCH Clinic Equipments---------------------------------------------------------------------------35 Table 3.2 Availability of Essential Labor, Delivery and postnatal Care equipment----------------------------------------------------------------------37 Table 3.3 Availability of Essential Equipment for Caesarian Section--------------------------------------------------------------------------------40 Table 4.1 Drugs Recommended to Mothers for Routine ANC-----------------------------------------------------------------------------------42 Table 4.2 Laboratory Tests Recommended to ANC Mothers--------------------------------------------------------------------------------43 Table 4.3 Drugs Used by Health Care Workers for Management of Pre-Eclampsia---------------------------------------------------------------------44 Table 4.4 Drugs Used by Health Care Workers for the Management of Dysfunctional Labor----------------------------------------------45 Table 4.5 Drugs Used by Health Care Workers for Management of Normal Delivery-------------------------------------------------------------------47 Table 4.6 Drugs Used by Health Care Workers for Management of Hemorrhage-----------------------------------------------------------------------48 Table 4.7 Drugs Used by Health Care Workers for Caesarian Section---------------------------------------------------------------------------------49 Table 4.8 Drugs Used by Health Care Workers for Management of Puerperal Sepsis------------------------------------------------------------------50

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Table 4.9 Drugs Used by Health Care Workers for Management of UTI---------------------------------------------------------------------------------52 Table 4.10 Drugs Used by Health Care Workers for Management of GUD--------------------------------------------------------------------------------53 Table 4.11 Drugs Used by Health Care Workers for Management of Gonorrhea---------------------------------------------------------55 Table 4.12 Drugs Used by Health Care Workers for Management of Acute PID--------------------------------------------------------------------------56

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ACKNOWLEDGEMENT

My sincere gratitude goes to the Takemi Program which provided the funds that made it possible for me to conduct the further analysis of the Cost Estimate Strategy (CES) Field Test in Kenya. To meet and establish new contacts with the international community at Harvard School of Public Health from whom I have learnt a great deal of new information. The knowledge that I gained from auditing the classes that I was able to attend will go along way in improving my performance. I acknowledge the contributions of the faculty in the Department of International Health at Harvard School of Public Health. My appreciation goes to Marc Mitchell who was always ready to give technical advice. To Michael R.Reich the Takemi Program Director, whose talks on issues pertaining to politics has made me change my attitude towards politics. To Catherine Haskell the Program Coordinator and Nadie Trotman the Staff Assistant for their support that made it easy for me to complete my work. To my fellow colleagues, the Takemi Fellows, who were great source of inspiration. Special Thanks go to Dennis Ross-Degnan Associate Professor of Harvard Medical School and Director of Research, Harvard Pilgrim Health Care Drug Policy Research Group for his technical advice and great interest in the study. Dennis I shall forever be indebted to you.

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LIST OF ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care ASTGs Adjusted Standard Treatment Guidelines BCG Bacilli Calmette Guerin CEOC Comprehensive Essential Obstetric Care CES Cost Estimate Strategy CO Clinical Officer DHMT District Management Team DHMTs District Health Management Teams EPI Expanded Program on Immunization GP General Practitioner KEMSA Kenya Medical Supplies Agency HIS Health Information System HIV Human Immunodeficiency Virus IMCI Integrated Management of Childhood Illnesses MEDS Mission for Essential Drugs and Supplies MCH Maternal Child Health MOH Ministry of Health MW Midwife NHSSP National Health Sector Strategic Plan NMW Nurse Midwife OB/GYN Obstetrician Gynecologist RH Reproductive Health RPM Rational Pharmaceutical Management SIDA Swedish International Development Agency STGs Standard Treatment Guidelines TB Tuberculosis USAID United States Agency for International Development VAT Value Added Tax

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EXECUTIVE SUMMARY At the 1994 Cairo International Conference on Population and Development, recommendations called for action to reduce maternal morbidity and mortality among other things. Governments and donor agencies responded to the call by supplying the reproductive health commodities that are necessary for improving women’s reproductive health (RH) care services. This assistance was however being provided without the benefit of information necessary for determining the cost and quantities of commodities required for improving the provision of the RH care services to women. There was therefore a need for a systematic approach to asses supply requirements to provide adequate RH services. In response to the need, the Rational Pharmaceutical Management (RPM) and MotherCare both funded by the USAID developed the Cost Estimate Strategy (CES) tools. The Cost Estimate Strategy tools were designed to identify ways to improve the availability and use of reproductive health drugs, medical supplies and equipment at the various levels of health care. They also provide a framework for using cost information for policy making and planning based on the cost of commodities and equipment and the standard treatment guidelines of a particular country. The tools were field tested in Kenya between September 1997 and June 1998 in four provinces namely: Nairobi, Central, Nyanza and Western. Except for Nairobi, four districts: Nyeri and Nyandarua in Central, Nyamira in Nyanza and Bungoma in Western were selected for the field test. The primary objective of the field test was “to asses the feasibility of the CES approach and the extent it proved to be feasible, to determine ways of improving it as a management tool”. Twenty two reproductive health conditions covering ANC, delivery services, maternal and neonatal complications and; selected reproductive tract infections were selected for the exercise. Data was collected from the central level, private pharmacies, government, mission and private facilities at all levels of care within the four districts and Nairobi province. Analysis of data obtained from the field test was conducted from the national level perspective. The tools were proven useful for generating data and information at the national level for decision making and planning interventions. At the national level dissemination workshop for the CES field test report held in 1999, participants drawn from the national, provincial and the district levels recommended among other things that i) reproductive health commodity needs be quantified using tools such as CES, especially at the provincial and district levels and; ii) the CES tools be reviewed to allow district level officials establish the commodities needs for all health

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care services at the district level. These recommendations called for a study to conduct further analysis of the CES field test data from the districts’ perspective and review of the existing CES model. The study identified the following research questions:

• Can the CES tools and approach also generate practical data and information for decision making, planning interventions and monitoring progress at the district level in regard to reproductive health?

• With modification, would CES tool generate data and information for decision making and planning interventions at the district level for all the high priority health packages as stipulated in the National Health Sector Strategic Plan (1999-2000)?

Findings from the study have shown that the CES tools can generate practical data and information for decision making and planning interventions at the district level in regard to reproductive health. Primarily however, for the CES tools and approach to be applicable at the district level for all the health services, the services and drugs, supplies and equipment should be easily separated from rest of the system. Application of the current computer based costing model of the CES at the district level is limited due to the inadequate computer technology. Weak demographic data, epidemiological data, inventory of drugs, supplies and equipments and local cost estimates of the individual items further compounds the use of the CES model at the district level. A simplified costing model for use at the district level would be more appropriate. The findings have also shown that the current CES model does not take into account staffing, training, operating costs and the commodity needs for the community based health care services. To estimate the cost of providing health services of a particular package, there is need to include these variables in the CES model. None the less, at the district level where the CES model is applicable, it can be a good tool for quantifying commodity needs and estimating cost. In addition, some of its components can be developed further into monitoring tools for the District Health Management Teams (DHMTs) to monitor the rational use of drugs and availability of essential commodities and equipment. However, strengthening the DHMTs capacity would be required.

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CHAPTER 1

INTRODUCTION Background Factors contributing to poor quality of health care services in Kenya are multifaceted and can include inequitable distribution or lack of access to health services, insufficient resources, poor performance of the health system, inappropriate health seeking behavior etc. To address issues that relate to poor quality of health care services in general, the Ministry of Health, Kenya has instituted a Health Sector Reform process whose goal is to “promote and provide quality, curative, preventive, promotive and rehabilitative services to all Kenyans”. The Ministry has developed a 5 years National Health Sector Strategic Plan (NHSSP-1999-2004) that articulates the areas to be focused on. Based on available data on the burden of disease, cost-effectiveness of the interventions and the health outcomes in relation to health expenditure, 6 high priority health packages have been identified namely:

Malaria prevention and treatment package Reproductive Health (RH) package HIV/AIDS/TB prevention and management package Integrated Management of Childhood Illnesses (IMCI) package Expanded Program on Immunization (EPI) Control and prevention of major environmental health related communicable

diseases such as Cholera, Typhoid, and Dysentery as well as food safety. In the context of the Health Sector Reform process, it is envisaged that the aforementioned goal will be achieved through decentralization, which entails delegation of power and transfer of authority for planning, management, resource allocation and decision making from central level to the periphery. It is however recognized that for the decentralization to be effective, there is a need for among other things generation of data and information at the district level that the district health managers can use for decision making, planning interventions and monitoring progress. Cost Estimate Strategy (CES) At the 1994 International Conference on Population and Development held in Cairo, recommendations called for actions to reduce maternal morbidity and mortality. Governments and development partners pledged to support those actions by among other things supplying commodities that will ensure provisions of quality RH care services. However, this assistance was being provided without the benefit of information necessary

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for determining the cost and quantities of commodities needed for effective implementation of RH programs. In response to the need for a systemic approach to asses supply requirements to provide adequate RH services, the Cost Estimate Strategy (CES), a set of tools was designed by the Rational Pharmaceutical Management and Mother Care both funded by the USAID. The CES is designed to identify ways to improve the availability and use of reproductive health drugs, medical supplies and equipments at different levels in the health care system. In addition, it provides the framework for using cost information for policy making as well as for planning, based on the cost of commodities and the standard guidelines of treatment for the specific country being considered. The CES consists of three components: the normative cost estimate, based on international standard treatment guidelines and prices; the country-specific cost estimate, based on local epidemiologic and service utilization data, and commodity prices; the actual cost estimate, as a result of a survey of observed service provider and consumer behavior and; of the performance of public and private drug management and supply systems and; a policy decision making workshop, a framework for using the survey findings and outputs from the previous stages for the development of a prioritized, phased work plan for improving the management of RH drugs and supplies. The CES Field Test in Kenya The CES tools were field tested in Kenya between September 1997 and June 1998 with technical and financial assistance from Rational Pharmaceutical Management Project of the USAID. The field test was conducted in four (4) provinces namely Nairobi, Central, Nyanza and Western. Except for Nairobi, four (4) districts were randomly selected from a list of sixteen (16) from districts in the other three (3) provinces. The primary objective of the field test was to asses the feasibility of the CES approach and the extent it proved to be feasible, to determine ways of improving it as a management tool. The field test consisted of 6 study components namely:

Estimating local costs of treating selected RH conditions Estimating local costs of medical equipment items needed to deliver the essential

RH services Examining Variations in costs of RH commodities when purchased locally by

health facilities or in private pharmacies Examining availability of key drugs, medical supplies and equipment items in

government, mission and private health facilities and in private pharmacies. Surveying reported RH treatment practices among government, mission and

private medical personnel and among private pharmacy personnel.

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Assessing actual RH treatment practices for key RH conditions by reviewing medical records at health facilities, treatment cards retained by pregnant or newly delivered mothers or in simulated visits to private pharmacies.

A set of six forms were used for data collection. They included the following:

Health Facility Survey Form; Patient Contact Form; Health Care Provider Form; Mothers’ Interview Form; Maternal History Form and; Pharmacy Survey Form.

See attachments in Annex 5 Data was collected from the central level, private pharmacies, government, mission and private facilities at all levels of care within the 4 districts and Nairobi province. Data was analyzed using Epi info Version 6.03, SAS or Quattro-Pro. The analysis was from a national level perspective. Setting up the CES in Kenya The setting up of CES field test involved among other things selection of the RH conditions and services to be studied. Treatment requirements (drugs, supplies and equipments) for each selected case were also determined thus yielding the Adjusted Standard Treatment Guidelines. In addition, local and international prices for drugs, medical supplies and equipments required for the treatment of the selected RH conditions were determined. The prices formed the bases for comparisons with MEDS prices. The process followed is as described below. a. Selection of important RH conditions and services A total of 22 important RH conditions and services covering ANC, delivery services, maternal and neonatal complications and selected reproductive tract infections were selected for the field test (see Annex 1). The requirements per case for the treatment of the selected RH conditions and services were estimated using the treatments as outlined in the Ministry of Health’s Clinical Guidelines (1994) referred to as the Kenya Standard Treatment Guidelines (STGs) in this study. In order to do this, the existing STGs were validated and /or updated where necessary by an expert advisory team comprising of senior local nurses and obstetrician/gynecologists. For each of the selected RH conditions and services, the team reached a consensus on the adequacy of the treatment regimen described, including dosage and duration of the drugs of choice, and estimated the type and number of medical supply items needed to implement the treatment ( medical supplies and equipments were not outlined in the STGs). Through this process, an adjusted STGs (ASTGs) were developed for the field test.

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It is important to note that the study team rather than take the RH package as described in Kenya; they selected RH conditions that were important from the national level perspective. At the district level, each District Health Management Team (DHMT) would have to select conditions that are important from their district’s perspective. b. Determination of local prices (National level) A local procurement price for drug and supply requirements as per the Kenyan ASTGs, needed to be determined for each item (generally equivalent to a wholesale price plus fixed administrative markup). Since the Kenyan MOH procures its drugs and supplies for health facilities in drug kits at a single tendered price for all items included, it was impossible to identify the individual unit prices paid for each item contained in the kits. However most of the drugs and supplies in the ASTGs are also supplied by MEDS which operates a large centralized, low-cost procurement system to service mission facilities. In this regard therefore, the MEDS list prices formed the basis of the procurement price estimates. Data for drugs, expendables and equipment in the ASTGs was also requested from Pharmaciens Sans Frontiers and added to the database. In addition to the above, the price list for reproductive health expendables and equipments was requested from ten private suppliers. Seven of the ten suppliers contacted completed the unit cost forms by providing wholesale cost that included transport to Nairobi. Where VAT tax (16%) applied to an item, it was added. The median unit cost from all the suppliers was taken as the unit cost for drugs, expendables and equipment. The unit cost for drugs and equipment determined through the described process was from a national level perspective. This is due to the current procurement system that is central. This unit cost will therefore not be applicable at the district level. However, since some procurement goes on at the districts albeit within a certain ceiling, data on costs can be collected that can be used for comparing costs between districts and other levels. Rationale for the further Analysis of the Cost Estimate Strategy field test data From the analysis, the CES tools were proven useful for generating data and information on the RH commodity needs to improve RH services at the National level. In this regard, the CES approach has been found to be a useful management tool. The CES field test report was disseminated at a national level workshop in Kenya in 1999 and at a Regional workshop for Eastern, Central and southern African Countries held in Mombasa, Kenya in 2000. During the two workshops, CES approach was found to be a useful management tool and one of the recommendations made was that the report be disseminated as widely as possible to facilitate its implementation. In addition, the National level workshop also recommended among other things that;

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• Reproductive health commodity needs be quantified using tools such as CES, especially at the provincial and district levels in Kenya

• Provincial and district officials be given clear responsibility, authority, and necessary technical support to monitor the availability of essential reproductive health commodities and act on observed needs at the facilities

• Materials to be developed to support training at the district level on selection and quantification of drugs and other commodities at the provincial and district levels.

• The guidelines be reviewed to allow district level officials establish the commodities needs for all health care services at the district level.

Recommendations made at the national level workshop if implemented would contribute to the process of health sector reforms agenda. However, the analysis of the data so far conducted has only generated data and information that is useful for decision making and planning interventions at the national level. To implement the above recommendation therefore, there is a need to prove that the CES tools can also generate data and information for decision making and planning interventions at the district level. This then calls for further analysis of the CES field test data from the district perspective. The Ministry of Health Kenya is committed to the Health Sector Reforms whose Key strategy is the decentralization process. In the context of decentralization the Ministry’s policy is to ensure that the district level health mangers are equipped with knowledge and health management skills that will enable them take up their increased management roles. The CES approach among others provides an opportunity to the Ministry of Health to build the management capabilities of the health mangers at the district level, the foci of decentralization. The National Health Sector Strategic Plan has identified six high priority health packages to be focused on. Data and information generated from the analysis so far conducted of the CES field test provides for reproductive health only. To make the National Health Sector Strategic Plan operational through the decentralization process among other things, data and information for all the six identified high priority health packages need to be generated for decision making and planning interventions. This then calls for CES tools to be reviewed to allow district level officials establish all the commodities needs at that level. The Research Questions Based on the recommendations made during the National level dissemination workshop, the question that arises is:

• Are the CES tools and approach applicable at the district level? To respond to the above question, further analysis of the CES field data will focus on two specific questions. The two questions are:

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• Can the CES tools also generate practical data and information for decision making and planning intervention at the district level in regard to reproductive health?

• With modification, could the CES tools be used for generating practical data and information for decision making and planning intervention at the district level for all the six high priority health packages? Key issues include i) are services & drugs/supplies/equipment easily separated from the rest of the system ii) could some key components/indicators be developed to link theoretical treatment approach to real world services.

This will contribute to the efforts of the MOH in strengthening management skills of the district level managers to carry forward the decentralization process.

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CHAPTER 2

METHODOLOGY

In “Can the CES tools also generate practical data and information for decision making and planning interventions at the district level in regard to Reproductive Health” the existing data files of the Kenya CES field test data will be used. In “With modification, could the CES tools be used for generating practical data and information for decision making and planning intervention at the district level for all the six high priority health packages” the existing CES model will be used. Study Sites and Sources of Data and Methods The Kenya CES field test carried out between September 1997 and June 1998 was conducted in four provinces namely Nairobi, Central, Nyanza and Western. The provinces were intentionally selected by the MOH to represent a range of conditions in the non-arid portions of rural, Kenya. Except for Nairobi, four districts were randomly selected from the other provinces. The districts included Nyeri and Nyandarua in Central, Nyamira in Nyanza and Bungoma in Western. Within the districts, facilities were selected through a stratified random sampling method. Private pharmacies were randomly selected from those that were in the same geographical area as the hospitals included in the sample. Data was collected from the central level and from a total of 15 hospitals, 3 maternity homes, 29 health centers, 9 dispensaries and 98 private pharmacies (24 pharmacies with stock surveys and pharmacist interviews and 74 pharmacies with simulated purchase survey). The facilities included were operated by government, mission and private sectors. A total of 124 mothers for ANC were interviewed. In the Pharmacy survey, simulating clients were attended to by 57 registered pharmacists and 17 non-pharmacist pharmacy staff. Face to face interviews at the 24 pharmacies was conducted with 24 pharmacists and 15 non-pharmacist staff. Data collected included information that pertains to the facility (management, infrastructure and equipment check list and drug and supply check list); self reported information by the health care providers on their practices that was cross checked with actual practice pattern that were recorded in the medical records; information regarding ANC services and labor/delivery collected from mothers and; information about reported practices for ANC services at pharmacies which was cross checked by a simulated purchase survey.

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Methods of data collection included: • Review of published documents and reports; • Special reports from computerized MOH Health Information System (HIS); • A mini survey of drug, medical supply and equipment supplies; • A stock survey and medical records review at government, mission and private

health facilities; • A stock survey and simulated purchase survey at private pharmacies and ; • Interviews with local key informants, health personal, staff at private pharmacies,

women attending antenatal care (ANC) and newly delivered mothers. Data collection and Analysis After research questions were identified, existing field test data files and the CES model were used. Literature and document review was also conducted. Consultations were held with members of the CES Kenya team, RPM/MotherCare Team and faculty members at Harvard School of Public Health, Department of Population and International Health. This study did not conduct further analysis of the field test data obtained from private pharmacies through face to face interviews and simulation surveys. This is because the proposed health reforms in Kenya do not include the functions of the private pharmacies. Excel software was used for data analysis. Information gathered was compared and presented in tabular and graphic forms.

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CHAPTER 3

PART I CAN THE CES TOOLS ALSO GENERATE PRACTICAL DATA AND INFORMATION FOR DECISION MAKING PLANNING INTERVENTIONS AND MONITORING PROGRESS AT THE DISTRICT LEVEL IN REGARD TO REPRODUCTIVE HEALTH? Findings of further data analysis of the CES field test from the district perspective are discussed below in the following four categories:

• Availability of RH basic commodities and equipment at sample facilities; • Practice patterns; • Mothers’ interviews and; • Estimated costs for treating RH conditions and equipment.

AVAILABILITY OF RH BASIC COMMODITIES AND EQUIPMENT AT SAMPLE FACILITIES The study looked at the availability of selected drugs and medical supplies present at the sampled facilities at the time of the survey regardless of quantity. Health facilities at the same level of care (hospitals, health centers, maternity and dispensaries) are required by policy to offer the same type of health care services including those that pertain to reproductive health. A general overview of the availability of RH commodities at the various levels of care in the sampled districts is presented in Table 2.1 in the Annex 2. The data presented is not disaggregated by districts but summarized by the level of care and by the type of management (government, mission and private). The commodities are grouped into three categories:

• Drugs and medical supplies that should be available at all level of care; • Drugs and medical supplies that should be available at facilities performing

normal deliveries (health centers and above) and; • Drugs and medical supplies that should be available at facilities offering obstetric

surgery (hospitals). Although the number of samples is not comparable, government facilities generally tended to have more stock out items at the time of the survey than did mission and private facilities. 56% of commodities analyzed, were present in government hospitals as compared to 87% and 74% in mission and private hospitals respectively. Availability of drugs and supplies was generally lower at the government and mission health centers and dispensaries than in the hospitals by the same management. Compared to 74% of private health centers, only 53% and 67% of government and mission health

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centers had stock of the analyzed commodities respectively. The proportion of maternity homes (all private) and dispensaries (government and mission) that had stock of analyzed commodities were 60% and 27% respectively. a) Availability of Key Commodities from the Districts’ Perspective Availability of drugs and medical supplies at the facility level is one of the factors that contribute to the provision of quality health care services. Lack of key drugs and medical supplies implies that the facility has inadequate capacity to provide health care services that are appropriate for its level. The study looked at the availability of some key commodities at the time of the survey in the sampled facilities. The data is disaggregated by sample districts and by the different types of management to provide for comparison of commodity availability between the districts and by the different types of management (see Table 2.2 in Annex 2). Availability of analyzed key commodities was generally lower at government facilities than at mission and private facilities. This pattern was observed from the level of the hospitals to the lowest level of care, the dispensaries. 48% of government facilities had key commodities at the time of the survey compared to 73% and 64% of mission and private facilities respectively. Government health centers and dispensaries were noted as the facilities with the lowest availability of all the key commodities. This depicts poor provision of health care services that may lead to under utilization of the facilities. This could be one of the factors contributing to over congestion at government hospitals a phenomenon that has already been observed in many government hospitals in Kenya, including the tertiary levels of health care. There were some key drugs and medical supplies whose low availability is of a major concern considering that they are required for core management of RH conditions some of which, are life threatening. For example: i) Amoxicillin A basic drug that is necessary at all levels of care for management of infections including life threatening conditions such as puerperal sepsis was out of stock in many facilities particularly those managed by government. Figure 1 below is a presentation of Amoxicillin availability in all facilities. Availability in government facilities was highest in Nairobi at 50% followed by Nyandarua at 43 %, Nyeri at 29% and Bungoma and Nyamira at 22% and 14% respectively. Availability at the mission facilities was 100% in all the districts. In private facilities, availability was 100% in all the districts but Nyandarua where availability was 67%.

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Figure 1

Availability of Amoxicillin

0%20%40%60%80%

100%120%

BUNGOMA

NAIROBI

NYAMIRA

NYANDARUA

NYERI

Districts

Perc

enta

ges

GovernmentMissionPrivate

Many government health centers and dispensaries had no stocks of Amoxicillin compared to 100% availability in mission and private lower level facilities Nyamira District Hospital, a government hospital and a referral hospital within the district was also found lacking stock of Amoxicillin. All other hospitals had stocks of Amoxicillin ii) Normal Saline An essential commodity for all levels of care above the dispensary level for the management of some RH conditions for example obstructed labor, hemorrhage and acute pelvic inflammatory disease was out of stock in all hospitals by all types of management in Nyandarua, in the private hospital in Nairobi and in the government hospitals in Nyeri and Bungoma. Many government health centers in all districts reported a stock out of normal saline. Figure 2 below is a presentation of normal saline availability at all facilities. In government facilities, availability was highest in Nairobi at 43% followed by Bungoma at 29%, Nyamira and Nyandarua at 20% each and Nyeri at 17%. Availability was at 100% in mission facilities in Bungoma, Nairobi and Nyeri and at 50% and 0% in Nyamira and Nyandarua respectively. In private facilities, it was at 100% in Bungoma, Nyamira and Nyeri and at 67% and 0% in Nyandarua and Nairobi respectively.

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Figure 2

Availability of Normal Saline at all Facilities

0%20%40%60%80%

100%120%

BUNGOMA

NAIROBI

NYAMIRA

NYANDARUA

NYERI

Districts

Perc

enta

ges

GovernmentMissionPrivate

Availability at government health centers in all the districts was very low. Mean percent of availability was 20%. The same was also observed for I.V set an essential commodity for setting up I.V fluids (normal saline, dextrose 5% and blood transfusion) where the mean percent of availability was 21%. This finding implies that women presenting at most of these facilities with emergencies have to be referred to higher levels of care thus causing delay and putting the mother and/or baby at risk. iii) Non Sterile Gloves and Sterile Gloves. Health care workers use gloves as a barrier to prevent transmission of microorganisms between the patients and themselves. While sterile gloves are used for aseptic procedures, non sterile gloves are used for handling potentially infectious materials such as blood, feces, wound secretions, mucus membrane lesions, skin lesions and when the health care worker has non intact skin on hands The table below is a presentation of the availability of both types of gloves at the sample districts by the different types of management. It is shown that in both the government and private facilities in all the districts, availability of sterile gloves was higher than the availability of non sterile gloves. In some districts there were facilities managed by mission or private that had no stocks of non sterile gloves.

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Table 1: Availability of Non Sterile and Sterile Gloves District Government Facilities Mission Facilities Private Facilities Non

Sterile Sterile

Non Sterile

Sterile

Non Sterile

Sterile

Bungoma 11% 86% 50% 100% 0% 100% Nairobi 25% 43% 100% 100% 50% 100% Nyamira 71% 80% 100% 50% 0% 100% Nyandarua 43% 80% 0% 100% 67% 100% Nyeri 71% 83% 75% 75% 0% 100% Availability of gloves at the facility level is of great importance. In this error of HIV/AIDS and considering that over 50% of our hospital beds are occupied by HIV/AIDS positive patients, health care workers need gloves as one of the requirements for observing infection prevention practices. In a situation where there is a stock out of non sterile gloves but a stock of sterile gloves, there is likelihood that the sterile gloves may be used inappropriately thus depleting the stock. (b) Equipment Availability of equipment at the facility level is yet another factor that contributes to the facility’s capability to provide quality health care services appropriate for its level. Lack of individual items or full sets of equipment impacts negatively the provision of quality health care services. To study equipment necessary for providing the selected 22 RH services, the equipment was divided into three packages namely:

• Basic equipment for maternal and child health (MCH) clinic, • Basic equipment for labor, delivery and postnatal care • Basic equipment for obstetric surgical procedures

Equipment was counted as present if it was in a functional state. The number of individual items that are absolutely essential for providing minimally acceptable level of care was derived from the ASTGs. i) Basic Equipment for MCH Clinic ANC mothers are seen at the MCH clinics where they are screened to identify potentially high risk conditions and are prepared for the birth process and emergencies. The study obtained information on the availability of Basic MCH equipment sets at the sample facilities. Since many of the sets were incomplete, four items considered absolutely essential to maintain the minimum level of MCH services were selected for availability comparison at the various levels of care by the different types of management in the sample districts. The four items are adult scale, adult stethoscope, fetal stethoscope and sphygmomanometer.

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Availability of the four items considered absolutely essential to maintain the minimum level of MCH services was generally high at all levels of care by the different types of management in the sample districts. Availability at the mission facilities was 98% followed by private facilities at 90% and government facilities at 89% (see Table 3.1 in Annex 3). It is however important to note that the private hospital in Nairobi had no stock of any of the four items. A few government health centers also lacked stocks of the four items. In country where 94% of mothers attend ANC at least once during pregnancy, the high availability of the four essential items is a good indication that minimum level of ANC services is being provided at the MCH clinics. Whether the mothers are satisfied with the services needs to be determined. ii) Basic Equipment for Labor, Delivery and Postnatal Care Availability of basic equipment sets for labor, delivery and postnatal care services indicates the facility’s readiness to provide the services. There was also incompleteness of the sets and therefore, seven items that were considered absolutely essential to provide the minimum level of services in labor, delivery and postnatal care were identified for review of their availability. These items were: suction machine, adult stethoscope, fetal stethoscope, sphygmomanometer, artery forceps 8”, mackintosh sheet and cord scissors, 10cm. Availability of the items analyzed was lower in government facilities than in either the mission or private facilities. The total mean percent of government facilities that had the analyzed items was 44% compared to 78% and 93% mission and private facilities respectively. Availability was noted to be high at the hospital level by all types of management in the sample districts. However, availability was notably low at the government health centers at 33% compared to 100% and 71% at the private and mission health centers respectively (see Table 3.2 in the Annex 3). Unavailability of some of the essential equipment items at the various levels of care is of concern. Figure 4 below for example is an illustration of the availability of the suction machines, a life saving piece of equipment required at all facilities conducting deliveries..

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Figure 3

Availability of Suction Machine at all Facilities

0%20%40%60%80%

100%120%

BUNGOMA

NAIROBI

NYAMIRA

NYANDARUA

NYERI

Districts

Perc

enta

ges

GovernmentMissionPrivate

In government facilities, availability was highest in Nyeri at 50% followed by Bungoma and Nairobi at 43% and Nyamira and Nyandarua at 40%. There was no suction machine in the mission and private facilities visited in Bungoma district and in the mission facilities visited in Nyamira district. While most of the hospitals by all types of management had a suction machine, it was not available in Nyandarua District Hospital, managed by the government and in the mission and private hospitals in Bungoma district Availability was also low at the government health centers with a mean percent of 34%. The mean percent availability at the mission health centers was 50% while at the private health centers and the maternity homes it was 100%. Implicitly, lack of the item implies inadequate capacity for the facilities to provide health care services that are appropriate for their level. Subsequently, this may contribute to low use of services and loss of confidence with the affected facilities. iii) Equipment Required for Caesarian Section Services One of the essential obstetric emergencies considered a component of comprehensive essential obstetric care (CEOC) is caesarian section. At the time of the survey as previously noted with the availability of other equipment sets, most sets for caesarian section were also incomplete. Eight items that were considered absolutely essential were therefore identified for review of their availability. The items were: blade handle, any artery forceps, any sponge forceps, any tissue forceps, lagenback retractor, any mayo scissors, needle holder and abdominal sheet or green towel. Since caesarian sections are not performed at the lower level facilities, only hospitals were considered for caesarian section services.

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Availability of the items analyzed was generally high at all the hospitals by the three types of management. The total mean percent of availability was 89%, 97% and 92% in all the hospitals managed by government; mission and private sectors respectively (see Table 3.3 in Annex 3) Although there was a high level availability of most of the items at the hospitals’ by all types of management in the sample districts, it is important to not that six out of the fifteen hospitals did not have all the essential equipment items for caesarian section. For example, the lagenback retractor was the least available compared to the other items. Figure 5 below illustrates its availability at all the hospitals by the different types of management. It was not available at the mission and one of the government hospitals in Nairobi and; at the Nyamira and Nyandarua District Hospitals both managed by the government. Figure 4

Availability of Lagenback Retractor in all the Hospitals

0%20%40%60%80%

100%120%

BUNGOMA

NAIROBI

NYAMIRA

NYANDARUA

NYERI

Districts

Per

cent

ages Government

MissionPrivate

Lack of some of the essential equipment items indicates inadequate capacity of a facility to offer caesarian section. Implications of this is that hospitals that are referral institutions within the districts for cases requiring caesarian section are either having to refer the mothers to higher levels of care or providing substandard services. Again this can contribute to loss of confidence in the facility care by users and potential users, resulting in the low use of the facility for the service. PRACTICE PATTERNS Health care provider reported practices The field test study attempted to assess the treatment practices of the health care providers at the facilities visited versus the recommendations as stipulated in the Kenya Standard Treatment Guidelines (STGs). Eleven reproductive health conditions namely: ANC, Pre-Eclampsia, Dysfunctional labor, Normal Delivery, Hemorrhage, Caesarian

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Section, Puerperal Sepsis, Urinary Tract Infections, Genital Ulcer Disease, Gonorrhea, Acute Pelvic Inflammatory Disease were targeted. The health care providers included: obstetricians/gynecologists, general practitioners, clinical officers, nurse midwifes, nurses and midwifes. The analysis of available data has indicated a generally low use of the recommended drugs and laboratory tests and; use of other drugs and tests (not in the STGs) at all levels of care for all the targeted conditions. The analysis also shows that obstetricians/gynecologists are recommending use of drugs and tests as stipulated in the STGs than any of the other health care providers. In addition, they are also recommending use of other drugs more than any of the health care providers. See tables in Annex 4. Information on the low use of some of the routine and basic drugs as a preventive measure or treatment of conditions some of which are life threatening is of concern. For example: i) Provision of Iron Sulphate to ANC Mothers According to the STGs iron sulphate tablets should routinely be given to pregnant mothers. Information obtained from the analysis of available data indicates that a significant proportion of all health care workers are not routinely recommending use of iron sulphate to ANC mothers (see table 7 below). The table shows that the highest proportion of all health workers recommending use of iron sulphate to pregnant mothers is in Bungoma district at 27% followed by Nyeri at 24%, Nyamira at 23% and Nairobi and Nyandarua at 17% and 7% respectively. Table 2 : Health Care Workers Recommending use of Iron Sulphate to ANC Mothers

Districts Staff Cadre Nairobi Nyeri Nyandarua Bungoma Nyamira

Ob/Gyn 50% - 0% 100% - GP - 50% 0% 0% 50% CO 11% 20% 11% 7% 0% NMW 16% 18% 18% 17% 20% Nurse 10% 20% - 20% - MW 0% 11% - 17% - Mean % 17% 24% 7% 27% 23% Lack of routine recommendation of the iron sulphate to pregnant mothers is of concern considering that anemia in pregnancy, most of which is due to iron deficiency, is a major obstetric problem in Kenya. It is perhaps due to the lack of routine use that availability of iron sulphate was high at all levels of care by all types of management in the sample districts as noted earlier in the text.

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ii) Use of Ergometrine in Normal Delivery Table 5 below illustrates the use of ergometrine by all the health care workers in the sample districts. Use of ergometrine by all the health care workers was highest in Nyandarua district at 44% followed by Bungoma at 27, Nairobi at 24%, Nyeri and Nyamira at 21% and 9% respectively. Table 3 : Use of Ergometrine by all Health Care Workers in Normal Deliveries

Districts Staff Cadre Nairobi Nyeri Nyandarua Bungoma Nyamira

Ob/Gyn 100% - 100% 100% - GP - 50% 33% 17% 0% CO 0% 7% 22% 7% 17% NMW 10% 16% 20% 19% 11% Nurse 10% 20% - 0% - MW 0% 11% - 17% - Mean % 24% 21% 44% 27% 9% Ergometrine is given to the mothers with the delivery of the shoulders unless contraindicated. The drug augments adequate contraction of the uterus to prevent postpartum hemorrhage. Considering that postpartum hemorrhage has been found to be one of the major causes of maternal mortality in Kenya, health care workers should be encouraged to use ergometrine. iii) Use of Amoxicillin in the Management of Puerperal Sepsis Puerperal sepsis is another major cause of maternal mortality in Kenya. According to the STGs, the oral therapy for the management of puerperal sepsis entails a combination of Amoxicillin capsules and metronidazole tablets. Information obtained from the analysis of use of Amoxicillin in the management of puerperal sepsis is shown in table 6 below. The findings indicate that there is very low use of Amoxicillin. Only 12% of all health care workers in Nyeri district were using Amoxicillin for management of puerperal sepsis followed by 6% in Nairobi, 4% in Bungoma and Nyamira and 1% in Nyandarua.

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Table 4 : Use of Amoxicillin by All Health Care Workers for Management of Puerperal Sepsis

Districts Staff Cadre Nairobi Nyeri Nyandarua Bungoma Nyamira

Ob/Gyn 25% - 0% 0% - GP - 50% 0% 17% 0% CO 0% 7% 0% 7% 0% NMW 4% 4% 5% 1% 13% Nurse 0% 0% - 0% - MW 0% 0% - 0% - Mean % 6% 12% 1% 4% 4% The low use of Amoxicillin cannot be attributed to the low availability of Amoxicillin at the facility level noted earlier in the text. For example obstetricians/gynecologists and the general practitioners were mainly at the hospital level where availability of Amoxicillin at all hospitals by all types of management was 100%. In spite of this, use of the drug by the two cadres of staff was also low as shown in the above table. MOTHERS’ INTERVIEWS During the field test survey, a total of 124 mothers were asked about the tests and medications they were given during their first ANC visit. For this study, data on the use of iron sulphate was selected for further analysis. Information obtained from the further analysis indicate that a big proportion of the ANC mothers said that the health workers had recommended to them use of the iron sulphate (see table below). In Nyandarua district, all interviewed mothers in all the facilities by the different types of management said that they had been given iron sulphate. In the other districts, it ranged from 73% in government facilities in Nyeri to 100% in mission facilities in Nairobi and Nyamira districts. Table 5: ANC Mothers Given Iron Sulphate

Districts Admin Nairobi Nyeri Nyandarua Bungoma Nyamira Total

Government 83% 73% 100% 88% 84% 86% Mission 100% 75% 100% 80% 100% 91% Private - - 100% 75% - 88% As for the postnatal mothers, they were asked whether they had had to buy anything for their delivery. Although the sampled number of postnatal mothers was not comparable, information generated from those who responded indicates that things mothers are buying for their deliveries range from drugs to medical supplies. For example, information obtained indicates that mothers are buying non sterile gloves for their delivery as shown in table 8 below. In Nyeri district, all mothers interviewed in government facilities had

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bought non sterile gloves followed by 80% and 50% of mothers in government facilities in Nyamira and Bungoma districts respectively. In mission facilities only 20% of mothers interviewed in Bungoma district said they had bought non sterile gloves while no mother had bought the gloves in the private facilities. Table 6: Postnatal Mothers Who Bought Non Sterile Gloves

Districts Admin Nairobi Nyeri Nyandarua Bungoma Nyamira Total

Government 0% 100% - 50% 80% 58% Mission 0% 0% 0% 20% - 10% Private - - 0% 0% 0% 0% The tendency to ask mothers to purchase gloves was more in government than in mission or private facilities. ESTIMATED COST FOR TREATING RH CONDITIONS AND EQUIPMENTS Further analysis of the data on prices for commodities and equipment needed for treating RH conditions was not conducted in this study. Price data collected during the field test was from the national level perspective primarily because the nature of the system is that commodities are procured centrally. While procurement for government facilities is done centrally by the Kenya Medical Supplies Agency (KEMSA) or any other agent that the MOH may contract, for mission facilities it is carried out by MEDS, Kenya. Analyzing available data would therefore be a futile exercise because; it will not be from a district perspective which is of essence in this study. The above not with standing, minimum procurement still goes on at the district level. For example, the District Health Management Teams (DHMTs) using the cost sharing funds have authority to procure commodities and equipment but within a certain ceiling. If data on the commodities and equipments bought at the district level were to be collected, it would allow for comparison of costs at the district level. The finding would perhaps inform the decision making process at the district level. To estimate cost for treating RH conditions, there is need for information on quantification of commodity and equipment needs. Available data on quantification of the said needs is also from the national level perspective. This further compounds the further analysis of available data from the districts’ level perspective. None the less, in the context of decentralization, the MOH with support from Swedish International Development Agency (SIDA) has been piloting the “Pull” System of commodities and equipment as opposed to the “Push” System in six districts. This process has had a lot of support from the district level. The MOH therefore needs to scale up the project and strengthen the capacity of the DHMTs in quantification of commodity and equipment needs at their various districts.

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PART 11 WITH MODIFICATION, COULD THE CES TOOLS BE USED FOR GENERATING PRACTICAL DATA AND INFORMATION FOR DECISION MAKING AND PLANNING INTERVENTION AT THE DISTRICT LEVEL FOR ALL THE SIX HIGH PRIORITY HEALTH PACKAGES?

The study examined the existing CES tools and focused on two key issues namely:

• are services & drugs/supplies/equipment easily separated from rest of the system; • could some key components/indicators be developed to link theoretical treatment

approach to real world services Nature of Service Packages The study found that for the CES model to be applicable, services provided for the conditions under review should easily be separated from the rest of the system. Drugs, supplies and equipment used for the management of the said conditions should also be easily separated from the rest of the system. With reproductive health, the CES model application was possible due to the nature of the services provided for reproductive health conditions selected for the study. The services could be linked to well defined clinics and service delivery areas such as MCH, labor ward, maternity theater etc thus separating the services from rest of the system. Equipments used for the service delivery and some drugs and supplies could also be separated from rest of the system. For the other five high priority health packages the CES model would only be applicable to some especially those whose services including drugs , supplies and equipments can be separated from rest of the system. Examples of some of the packages include; the expanded program on immunization, prevention of malaria in pregnancy, prevention of mother to child transmission of the HIV virus, Antiretroviral therapy, treatment of TB, the VCT program etc. Usefulness of the Costing Model The study found that the CES current form of a computer based costing model has limitations in its application at the district level, more so at the lower levels of the health care system. This is due to the districts’ inadequate capacity in computer technology. In addition, the study also found that for the CES costing model to be applicable there is need for demographic data, epidemiological data, , inventory of drugs, supplies and equipment and local estimated costs of items. At the district level, this information is rarely available in a comprehensive and complete manner. This further compounds the

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application of the CES model at the district level as a tool for generating practical data and information for decision making and planning interventions. None the less, where the CES model is applicable, it can be a good tool for quantifying commodity needs and estimating cost. This approach can be used for strengthening the commodity quantification skills of the districts’ level health managers particularly in the six districts where the Ministry of Health is piloting the “Pull” system of commodities as opposed to the “Push” systems. There are lessons learnt to be drawn from the Coast General Hospital where the CES model was applied for quantifying commodities for estimating cost needs in the Maternity Department with some success. In the review of the CES model, it was noted that the model does note take into account staffing, training, and operating costs and therefore it is not appropriate to calculate the cost of a package of service. The inadequate number of staff at the district level and lack of targeted in service training and updates to strengthen the knowledge and skills of the health care providers’ impacts negatively on their capacity to provide quality health care services. In addition, lack of reliable information on the operating costs may be one of the factors contributing to the infectiveness of the referral system and the occasional interruption of essential utilities. Location of Services Provided It was also noted that the CES model does not take into account the provision of health care services at the community level. Each of the high priority health packages has a community component with a requirement for commodities. For example, a significant number of women in each district continue to deliver at home and an increasing number of HIV/AIDS patients are being taken care of at home under the home based care programs. Could the CES model be used for quantifying the commodity needs and estimating cost at the community level? Reported Treatment Patterns The review of the providers self reported practice patterns, a component of the CES approach has shown that health care workers are not routinely using the regimens recommended in the STGs. Since the regimens in the STGs are based on the Kenya Essential Drug List the district level health managers can use this component to develop monitoring tools for rational use of drugs. However, selecting useful conditions to monitor is important. As noted earlier in the text, due to incompleteness of equipment sets, items that are absolutely necessary for provision of minimum health care had to be identified for review of their availability. Based on this experience, local expertise for example the District Health management Teams (DHMTs) can draw lists of what is absolutely necessary for provision of health care at the district level. The lists can then be developed further into check lists that the DHMTs can use for monitoring of commodities and equipment.

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CHAPTER 4 CONCLUSION AND RECOMMENDATIONS Findings from the study have shown that the CES tools can generate practical data and information for decision making and planning interventions at the district level in regard to reproductive health. Primarily however, for the CES tools and approach to be applicable at the district level for all the health services, the services and drugs, supplies and equipment should be easily separated from rest of the system. Information obtained from the analyses of data on the availability of key commodities and equipment has shown a general tendency of stock outs in government managed health facilities than in either the mission or private managed health facilities. Government health centers and dispensaries reported more stock out than any other level of health care. Analysis of the information obtained from the health care providers on the self reported practices have shown that the health care workers are not routinely using the regimens recommended in the STGs. Also, contrary to the paradigm clinical officers are providing services related to pregnancy and delivery particularly at the lower levels of care where they are the ones in charge and therefore expected to give guidance in the provision of health care. Since the CES model is inherently computer based, its application at the district level is limited. In addition its application at the district level is further compounded by the need for demographic data, epidemiological data, inventory of drugs, supplies, equipment and; local estimates of cost all of which are very weak at the district level. In its current form, the CES model does not take into account staffing, training and operating costs. These variables can impact either positively or negatively the provision of quality health care services. It was also noted that the CES model does not take into account the commodity needs for provision of health care at the community level an aspect of health care provision that continues to expand. Needless to say, where the CES model is applicable, it is a good tool for quantifying commodity and equipment needs and estimating cost. Although there are some lessons learnt to draw from the experience of the Coast General Hospital the leadership and who is driving the program matters. The CES approach was donor driven and collapsed with the donor’s loss of interest in reproductive health. Local expertise can be used to draw check lists of essential commodities and equipment necessary for provision of minimum levels of health care. These check lists could be used for monitoring of the availability of the said commodities and equipment. Subsequently,

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availability of the said commodities and equipment could be used as an indicator of the facilities’ capacity to provide minimum health care. The above findings call for the following recommendations:

1. The Ministry of Health needs to expand the “pull” system of commodities and equipment supplies from the six districts to all the districts. To facilitate the process, the empowerment of the District Health Management Teams (DHMTs) to conduct quantification of commodity and equipment needs is called for. In addition, the capacity of the Kenya Medical Supplies Agency (KEMSA) a government body that procures medical drugs and supplies on behalf of MOH needs its capacity strengthened to handle a “pull” system as opposed to a “push” system.

2. Technical support needs to be given to the DHMTs to develop check lists that can be used as monitoring tools for the availability of essential commodities and equipments at the facilities’ level. They also need autonomy to maintain essential commodities and equipments in the facilities within their districts to ensure provision of minimum health care services. To achieve this there is a need to review the existing ceilings on how much the DHMT can spend from the money collected from the cost sharing programs.

3. Using the CES component on the health care providers self reported practice patterns, the DHMTs can identify some training needs of the health care provides. This would inform their decision when nominating providers for training and updates.

4. The current computer based model of the CES need to be transformed to a model that is applicable in an environment of inadequate capacity in computer technology.

5. The CES model requires revision to include staffing, training and operating costs. In addition, there is need to explore the possibility of whether the CES model could be used for quantifying the commodity needs and estimating cost for community based programs.

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REFERENCES Bungoma District Development Plan: 1997-2001 Clinical Guidelines for Diagnosis and Treatment of Common Health Conditions in Kenya, 1994 Clinical Guidelines for Diagnosis and Treatment of Common Health Conditions in Kenya, 2002 Health Management Information Systems: 1996-1999 Kenya Essential Drugs List, 2003 Kenya’s Health Policy Framework, 1996 Kenya Demographic and Health Survey, 1993 Kenya Demographic and Health Survey, 1998 Kenya Service Provision Assessment, 1999 Kenya Health Facilities Ration Kits, FY 2003/2004 National Dissemination Report on The Cost Estimate Strategy (CES) for improving the Availability and Use of Reproductive Health commodities Kenya Field Test Report, 1999 Nyamira District Development Plan: 1997-2012 Nyandarua District Development Plan: 1997-2001 Nyeri District Development Plan: 1997-2001 Regional Dissemination Report on The Cost Estimate Strategy (CES) for improving the Availability and Use of Reproductive Health commodities Kenya Field Test Report, 2000 The Cost Estimate Strategy (CES) for improving the Availability and Use of Reproductive Health commodities Kenya Field Test Report, 1998 The National Health Sector Strategic Plan: 1999-2004

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ANNEX 1 Selected RH Conditions and Services Antenatal Care

• Anemia iron/folic acid deficiency • Tetanus immunization* • Syphilis screening • Malaria screening and treatment

Maternal and Infant Birth Package

• Safe and clean delivery • Hypothermia prevention • Opthalmia neonatorum prevention • Newborn immunization*(first dose of BCG and Polio) • Asphyxia early treatment

Maternal and Neonatal Complications Related to Pregnancy and Delivery Infections:

• Neonatal sepsis • Maternal sepsis • Mastitis • Urinary tract infection

Other Complications

• Pre-eclampsia/eclampsia • Complications of incomplete abortion • Dysfunctional labor • Cesarean-section for obstructed labor • Perineal/cervical laceration • Hemorrhage

Reproductive Tract Infection

• Genital ulcer disease (syphilis) • Gonorrhea/Chlamydia • Pelvic inflammatory disease

(* Note: Vaccines are provided through EPI program)

27

ANNEX 2: Availability of RH Commodities at Sampled Health Facilities

28

Table 2.1: Facilities where RH Commodities were Available Type of commodity All

facilities % Hospitals Health Centers

Gov % Mis % Priv % Gov % Mis % Priv %

Maternity Homes %

Dispensary % Drugs for all facilities

amoxicillin benzathine pen. doxycycline f/ sulphate metronidazole mean percent

32/56 57% 42/56 75% 42/56 75% 46/56 82% 45/56 80% 68%

5/6 83% 5/6 83% 5/6 83% 5/6 83% 4/6 67% 80%

6/6 100% 6/6 100% 5/6 83% 3/6 33% 6/6 100% 80%

3/3 100% 3/3 100% 2/3 67% 1/3 33% 2/3 67% 67%

6/24 25% 21/24 88% 20/24 83% 22/24 92% 19/24 79% 70%

3/3 100% 2/3 67% 2/3 67% 3/3 100% 3/3 100% 73%

2/2 100% 1/2 50% 0/2 0% 2/2 100% 2/2 100% 50%

3/3 100% 0/3 0% 1/3 33% 1/3 33% 2/3 67% 52%

4/9 44% 4/9 44% 7/9 78% 9/9 100% 7/9 78% 62%

Drugs for facilities doing n/deliveries cotrimozale ergometrine lidocaine normal saline oxytocin mean percent

38/47 68% 36/47 64% 33/47 59% 20/47 43% 17/47 30% 52%

5/6 83% 2/6 33% 4/6 67% 3/6 50% 5/6 83% 63%

6/6 100% 5/6 83% 6/6 100% 5/6 83% 5/6 83% 93%

3/3 100% 3/3 100% 2/3 67% 1/3 33% 3/3 100% 87%

15/24 63% 17/24 71% 13/24 54% 5/24 21% 0/24 0% 42%

3/3 100% 3/3 100% 3/3 100% 2/3 67% 0/3 0% 73%

2/2 100% 2/2 100% 2/2 100% 1/2 50% 2/2 100% 90%

2/3 67% 3/3 100% 3/3 100% 3/3 100% 2/3 67% 87%

Drugs for hosp. offering OB surgery atropine crystalline pen dextrose 5% hydralizine pethidine suxamethonium

13/15 87% 15/15 100% 13/15 87% 14/15 93% 8/15 53% 13/15 87%

5/6 83% 6/6 100% 3/6 50% 5/6 83% 4/6 67% 6/6 100%

6/6 100% 6/6 100% 6/6 100% 6/6 100% 4/6 67% 5/6 83%

2/3 67% 3/3 100% 3/3 100% 3/3 100% 0/3 0% 2/3 67%

29

thiopentone mean percent

13/15 87% 85%

6/6 100% 83%

5/6 83% 90%

2/3 67% 71%

Supplies for all facilities glass slide syringe/ needle urine dipsticks VDRL kits mean percent

35/56 63% 44/56 79% 30/56 54% 25/56 45% 60%

5/6 83% 4/6 67% 4/6 67% 5/6 83% 75%

6/6 100% 5/6 83% 6/6 100% 6/6 100% 96%

2/3 67% 2/3 67% 2/3 67% 2/3 67% 67%

17/24 71% 19/24 79% 12/24 50% 9/24 38% 59%

2/3 67% 3/3 100% 2/3 67% 1/3 3% 67%

2/2 100% 2/2 100% 2/2 100% 1/2 50% 88%

1/3 33% 3/3 100% 1/3 33% 1/3 33% 50%

0/9 0% 6/9 67% 1/9 11% 0/9 0% 19%

Supplies for facilities doing n/deliveries branula cord clamps gauze/absorbent n/sterile gloves sterile gloves iv set jik (1 liter) sutures mean percent

17/47 36% 12/47 26% 32/47 68% 28/47 60% 38/47 81% 23/47 49% 23/47 49% 36/47 77% 55%

5/6 83% 2/6 33% 6/6 100% 5/6 83% 5/6 83% 4/6 67% 5/6 83% 5/6 83% 73%

6/6 100% 3/6 50% 6/6 100% 4/6 67% 6/6 100% 6/6 100% 1/6 17% 5/6 83% 77%

2/3 67% 3/3 100% 3/3 100% 2/3 67% 3/3 100% 2/3 67% 1/3 33% 3/3 100% 75%

1/24 4% 1/24 4% 13/24 54% 11/24 46% 17/24 71% 6/24 25% 15/24 63% 16/24 67% 42%

0/3 0% 1/3 33% 3/3 100% 3/3 100% 2/3 67% 1/3 33% 1/3 33% 2/3 67% 54%

2/2 100% 2/2 100% 0/2 0% 2/2 100% 2/2 100% 1/2 50% 0/2 0% 2/2 100% 69%

1/3 33% 0/3 0% 1/3 33% 1/3 33% 3/3 100% 3/3 100% 0/3 0% 3/3 100% 50%

Supplies for hosp. offering OB surgery: scalpel blades suction catheter syringe/needles, 5cc mean percent

13/15 87% 7/15 47% 10/15 67% 67%

5/6 83% 2/6 33% 1/6 17% 44%

5/6 83% 4/6 67% 6/6 100% 83%

3/3 100% 1/3 33% 3/3 100% 78%

Total mean % 64% 56% 87% 74% 53% 67% 74% 60% 27%

30

Table 2.2: Availability of Selected Key Commodities at Sample Facilities in the Sampled Districts

All Facilities with Commodities Hospitals Health Centers Dispensaries Item District Total Gov Mis Priv Gov Mis Priv Gov Mis Priv

M/home Priv Gov Mis

Bungoma 5/12 42%

2/9 22%

2/2 100%

1/1 100%

1/1 100%

2/2 100%

1/1 100%

1/6 17%

- - - 0/2 0%

-

Nairobi 7/11 64%

4/8 50%

1/1 100%

2/2 100%

2/2 100%

1/1 100%

1/1 100%

1/5 20%

- 1/1 100%

- 1/1 100%

-

Nyamira 4/10 40%

1/7 14%

2/2 100%

1/1 100%

0/1 0%

- - 1/4 25%

2/2 100%

- 1/1 100%

0/2 0%

-

Nyandarua 6/11 55%

3/7 43%

1/1 100%

2/3 67%

1/1 100%

1/1 100%

1/1 100%

2/4 50%

- 1/1 100%

1/1 100%

2/2 100%

-

Amoxicillin

Nyeri 5/12 42%

2/7 29%

2/2 100%

1/1 100%

1/1 100%

2/2 100%

- 1/5 20%

1/1 100%

- 1/1 100%

0/1 0%

1/1 100%

Mean % 32% 100% 93% 80% 100% 100% 26% 100% 100% 100% 40% 100% Bungoma 10/12

83% 7/9 78%

2/2 100%

1/1 100%

0/1 0%

2/2 100%

1/1 100%

5/6 83%

- - - 2/2 100%

Nairobi 10/11 91%

8/8 100%

1/1 100%

1/2 50%

2/2 100%

1/1 100%

0/1 100%

5/5 100%

- 1/1 100%

- 1/1 100%

-

Nyamira 8/10 80%

6/7 86%

2/2 100%

0/1 0%

1/1 100%

- - 3/4 75%

2/2 100%

- 0/1 0%

2/2 100%

-

Nyandarua 9/11 82%

7/7 100%

0/1 0%

2/3 67%

1/1 100%

0/1 0%

0/1 0%

4/4 100%

- 1/1 100%

1/1 100%

2/2 100%

-

F/Sulphate

Nyeri 11/12 92%

7/7 100%

4/4 100%

0/1 0%

1/1 100%

2/2 100%

- 5/5 100%

1/1 100%

- 0/1 0%

1/1 100%

1/1 100%

Mean % 93% 80% 30% 80% 75% 67% 92% 100% 100% 33% 100% 100% Syringe & Needles

Bungoma 10/12 83%

7/9 78%

2/2 100%

1/1 100%

1/1 100%

2/2 100%

1/1 100%

6/6 100%

- - - 0/2 0%

-

31

Nairobi 7/11 64%

5/8 63%

1/1 100%

1/2 50%

2/2 100%

1/1 100%

0/1 0%

3/5 60%

- 1/1 100%

- 0/1 0%

-

Nyamira 7/10 70%

4/7 57%

2/2 100%

1/1 100%

1/1 100%

- - 2/4 50%

2/2 100%

- 1/1 100%

1/2 50%

-

Nyandarua 11/11 100%

7/7 100%

1/1 100%

3/3 100%

1/1 100%

1/1 100%

1/1 100%

4/4 100%

- 1/1 100%

1/1 100%

2/2 100%

-

Nyeri 10/12 83%

6/7 86%

3/4 75%

1/1 100%

1/1 100%

1/2 50%

- 4/5 80%

1/1 100%

- 1/1 100%

1/1 100%

1/1 100%

Mean % 77% 95% 90% 100% 88% 67% 78% 100% 100% 100% 50% 100% Bungoma 3/12

25% 1/9 11%

1/2 50%

1/1 100%

0/1 0%

1/2 50%

1/1 100%

1/6 17%

- - - 0/2 0%

-

Nairobi 4/11 36%

2/8 25%

1/1 100%

1/2 50%

1/2 50%

1/1 100%

1/1 100%

1/5 20%

- 1/1 100%

- 0/1 0%

-

Nyamira 7/10 70%

5/7 71%

2/2 100%

0/1 0%

1/1 100%

- - 3/4 75%

2/2 100%

- 0/1 0%

1/2 50%

Nyandarua 5/11 45%

3/7 43%

0/1 0%

2/3 67%

0/1 0%

0/1 0%

0/1 0%

3/4 75%

- 1/1 100%

1/1 100%

0/1 0%

Regular Gloves

Nyeri 8/10 80%

5/7 71%

3/4 75%

0/1 0%

1/1 100%

2/2 100%

- 3/5 60%

1/1 100%

- 0/1 0%

0/1 0%

0/1 0%

Mean % 44% 65% 43% 50% 63% 67% 49% 100% 100% 33% 10% 0% Bungoma 9/10

90% 6/7 86%

2/2 100%

1/1 100%

1/1 100%

2/2 100%

1/1 100%

5/6 83%

- - - - -

Nairobi 6/10 60%

3/7 43%

1/1 100%

2/2 100%

1/2 50%

1/1 100%

1/1 100%

2/5 40%

- 1/1 100%

- - -

Nyamira 6/8 75%

4/5 80%

1/2 50%

1/1 100%

1/1 100%

- - 3/4 75%

1/2 50%

- 1/1 100%

- -

Nyandarua 8/9 89%

4/5 80%

1/1 100%

3/3 100%

1/1 100%

1/1 100%

1/1 100%

3/4 75%

- 1/1 100%

1/1 100%

- -

Sterile Gloves

Nyeri 9/10 90%

5/6 83%

3/3 100%

1/1 100%

1/1 100%

2/2 100%

- 4/5 80%

1/1 100%

- 1/1 100%

- -

32

Mean % 74% 90% 100% 90% 100% 100% 71% 75% 100% 100% - - Bungoma 4/10

40% 1/7 14%

2/2 100%

1/1 100%

0/1 0%

2/2 100%

1/1 100%

0/6 0%

- - - - -

Nairobi 5/10 50%

2/7 29%

1/1 100%

1/2 50%

2/2 100%

1/1 100%

0/1 0%

0/5 0%

- 1/1 100%

- - -

Nyamira 2/8 25%

1/5 20%

0/2 0%

1/1 100%

1/1 100%

- - 0/4 0%

0/2 0%

- 1/1 100%

- -

Nyandarua 5/9 56%

2/5 40%

1/1 100%

2/3 67%

1/1 100%

1/1 100%

1/1 100%

1/4 25%

- 1/1 100%

0/1 0%

- -

Branula

Nyeri 3/10 30%

1/6 17%

2/3 67%

0/1 0%

1/1 100%

2/2 100%

- 0/5 0%

0/1 0%

- 0/1 0%

- -

Mean % 24% 73% 63% 80% 100% 67% 5% 0% 100% 33% - - Bungoma 7/10

70% 5/7 71%

2/2 100%

0/1 0%

1/1 100%

2/2 100%

0/1 0%

4/6 67%

- - - - -

Nairobi 4/10 40%

2/7 29%

1/1 100%

1/2 50%

1/2 50%

1/1 100%

1/1 100%

1/5 20%

- 0/1 100%

- - -

Nyamira 3/8 36%

1/5 20%

1/2 50%

1/1 100%

1/1 100%

- - 0/4 0%

1/4 50%

- 1/1 100%

- -

Nyandarua 5/9 56%

1/5 20%

1/1 100%

3/3 100%

1/1 100%

1/1 100%

1/1 100%

0/4 0%

- 1/1 100%

1/1 100%

- -

I.V Set

Nyeri 4/10 40%

1/6 17%

2/3 67%

1/1 100%

0/1 0%

2/2 100%

- 1/5 20%

0/1 0%

- 1/1 100%

- -

Mean % 31% 83% 60% 70% 100% 67% 21% 25% 100% 100% - - Bungoma 6/12

50% 6/9 67%

0/2 0%

0/1 0%

1/1 100%

0/2 0%

0/1 0%

5/6 83%

- - - 0/2 0%

-

Nairobi 2/11 18%

2/8 25%

0/1 0%

0/2 0%

1/2 50%

0/1 0%

0/1 0%

1/5 20%

- 0/1 0%

- 0/1 0%

-

Jik

Nyamira 5/10 50%

5/7 71%

0/2 0%

0/1 0%

1/1 100%

- - 3/4 75%

0/2 0%

- 0/1 0%

0/2 0%

-

33

Nyandarua 6/11 55%

5/7 71%

0/1 0%

1/3 33%

1/1 100%

0/1 0%

1/1 100%

3/4 75%

- 0/1 0%

0/1 0%

0/2 0%

-

Nyeri

7/12 58%

5/7 71%

2/4 50%

0/1 0%

1/1 100%

1/2 50%

- 3/5 60%

1/1 100%

- 0/1 0%

1/1 100%

0/1 0%

Mean % 61% 10% 7% 90% 13% 33% 63% 50% 0% 0% 20% 0% Bungoma

5/10 50%

2/7 29%

2/2 100%

1/1 100%

0/1 0%

2/2 100%

1/1 100%

2/6 33%

- - - - -

Nairobi

4/10 40%

3/7 43%

1/1 100%

0/2 0%

2/2 100%

1/1 100%

0/1 0%

1/5 20 %

- 0/1 0%

- - -

Nyamira 3/8 36%

1/5 20%

1/2 50%

1/1 100%

1/1 100%

- - 0/4 0%

1/2 50%

- 1/1 100%

- -

Nyandarua 3/9 33%

1/5 20%

0/1 0%

2/3 67%

0/1 0%

0/1 0%

0/1 0%

1/4 25%

- 1/1 100%

1/1 100%

- -

Normal Saline

Nyeri 5/10 50%

1/6 17%

3/3 100%

1/1 100%

0/1 0%

2/2 100%

- 1/5 20%

1/1 100%

- 1/1 100%

- -

Mean % 26% 70% 73% 40% 75% 33% 20% 75% 50% 100% - - Bungoma 3/10

30% 1/7 14%

1/2 50%

1/1 100%

1/1 100%

1/2 50%

1/1 100%

0/6 0%

- - - - -

Nairobi 5/10 50%

2/7 29%

1/1 100%

2/2 100%

2/2 100%

1/1 100%

1/1 100%

0/5 0%

- 1/1 100%

- - -

Nyamira 1/8 13%

1/5 20%

0/2 0%

0/1 0%

1/1 100%

- - 0/4 0%

0/2 0%

- 0/1 0%

- -

Nyandarua 5/9 56%

1/5 20%

1/1 100%

3/3 100%

1/1 100%

1/1 100%

1/1 100%

0/4 0%

- 1/1 100%

1/1 100%

- -

Oxytocin

Nyeri 3/10 30%

0/6 0%

2/3 67%

1/1 100%

0/1 0%

2/2 100%

- 0/5 0%

0/1 0%

- 1/1 100%

- -

Mean % 13% 63% 80% 80% 86% 100% 0% 0% 100% 67% - - Total mean %

48%

73%

64%

76%

80%

79%

43%

63%

85%

67%

44%

60%

34

ANNEX 3: Availability of RH Equipment at Sampled Health Facilities

35

Table 3.1: Availability of Essential Basic MCH Clinic Equipment Item District All facilities with commodity Hospital Health Center Dispensary

Total Gov Mis Priv Gov Mis Priv Gov Mis Priv

M/home Priv Gov Mis

Bungoma 11/12 92%

8/9 89%

2/2 100%

1/1 100%

1/1 100%

2/2 100%

1/1 100%

5/6 83%

- - - 2/2 100%

-

Nairobi 9/11 81%

7/8 88%

1/1 100%

1/2 50%

2/2 100%

1/1 100%

0/1 0%

4/5 80%

- 1/1 100%

- 1/1 100%

-

Nyamira 10/10 100%

7/7 100%

2/2 100%

1/1 100%

1/1 100%

- - 4/4 100%

2/2 100%

- 1/1 100%

2/2 100%

-

Nyandarua 10/11 91%

6/7 86%

1/1 100%

3/3 100%

1/1 100%

1/1 100%

1/1 100%

3/4 75%

- 1/1 100%

1/1 100%

2/2 100%

-

Adult scale

Nyeri 11/12 92%

6/7 86%

4/4 100%

1/1 100%

1/1 100%

2/2 100%

- 5/5 100%

1/1 100%

- 1/1 100%

0/1 0%

1/1 100%

Bungoma 10/12 83%

7/9 78%

2/2 100%

1/1 100%

1/1 100%

2/2 100%

1/1 100%

4/6 80%

- - - 2/2 100%

-

Nairobi 9/11 81%

7/8 88%

1/1 100%

1/2 50%

2/2 100%

1/1 100%

0/1 0%

4/5 80%

- 1/1 100%

- 1/1 100%

-

Nyamira 10/10 100%

7/7 100%

2/2 100%

1/1 100%

1/1 100%

- - 4/4 100%

2/2 100%

- 1/1 100%

2/2 100%

-

Nyandarua 11/11 100%

7/7 100%

1/1 100%

3/3 100%

1/1 100%

1/1 100%

1/1 100%

4/4 100%

- 1/1 100%

1/1 100%

2/2 100%

-

Adult stethoscope

Nyeri 10/12 83%

6/7 86%

3/4 75%

1/1 100%

1/1 100%

1/2 50%

- 4/5 80%

1/1 100%

- 1/1 100%

1/1 100%

1/1 100%

Bungoma 12/12 100%

9/9 100%

2/2 100%

1/1 100%

1/1 100%

2/2 100%

1/1 100%

6/6 100%

- - - 2/2 100%

- Fetal stethoscope

Nairobi 8/11 73%

6/8 75%

1/1 100%

1/2 50%

2/2 100%

1/1 100%

0/1 0%

4/5 80%

- 1/1 100%

- 0/1 0%

-

36

Nyamira 10/10 100%

7/7 100%

2/2 100%

1/1 100%

1/1 100%

- - 4/4 100%

2/2 100%

- 1/1 100%

2/2 100%

-

Nyandarua 11/11 100%

7/7 100%

1/1 100%

3/3 100%

1/1 100%

1/1 100%

1/1 100%

4/4 100%

- 1/1 100%

1/1 100%

2/2 100%

-

Nyeri 12/12 100%

7/7 100%

4/4 100%

1/1 100%

1/1 100%

2/2 100%

- 5/5 100%

1/1 100%

- 1/1 100%

1/1 100%

1/1 100%

Bungoma 11/12 92%

8/9 89%

2/2 100%

1/1 100%

1/1 100%

2/2 100%

1/1 100%

5/6 83%

- - - 2/2 100%

-

Nairobi 9/11 81%

7/8 88%

1/1 100%

1/2 50%

2/2 100%

1/1 100%

0/1 0%

4/5 80%

- 1/1 100%

- 1/1 100%

-

Nyamira 8/10 80%

5/7 71%

2/2 100%

1/1 100%

1/1 100%

- - 2/4 50%

2/2 100%

- 0/1 0%

2/2 100%

-

Nyandarua 10/11 91%

6/7 86%

1/1 100%

3/3 100%

1/1 100%

1/1 100%

1/1 100%

4/4 100%

- 1/1 100%

1/1 100%

1/2 50%

-

Sphygmoma- nometer

Nyeri 10/12 83%

6/7 86%

3/4 75%

1/1 100%

1/1 100%

1/2 50%

- 4/5 80%

1/1 100%

- 1/1 100%

1/1 100%

1/1 100%

Mean % 91% 89% 98% 90% 100% 94% 67% 88% 100% 100% 92% 88% 100%

37

Table 3.2: Availability of Essential Labor, delivery and Postnatal Care Equipment Item District All facilities with

commodity Hospital Health Center M/home

Total Gov Mis Priv Gov Mis Priv Gov Mis Priv Priv Bungoma 3/10 3/7

43%0/2 0%

0/1 0%

1/1 100%

0/2 0%

0/1 0%

2/6 33%

- - -

Nairobi 6/10 3/7 43%

1/1 100%

2/2 100%

2/2 100%

1/1 100%

1/1 100%

1/5 20%

- 1/1 100%

-

Nyamira 3/8 2/5 40%

0/2 0%

1/1 100%

1/1 100%

- - 1/4 25%

0/2 0%

- 1/1 100%

Nyandarua 5/8 2/5 40%

1/1 100%

2/2 100%

0/1 0%

1/1 100%

1/1 100%

2/4 50%

- 1/1 100%

1/1 100%

Suction machine

Nyeri 7/10 3/6 50%

3/3 100%

1/1 100%

1/1 100%

2/2 100%

- 2/5 40%

1/1 100%

- 1/1 100%

Mean % 43% 60% 80% 80% 75% 67% 34% 50% 100% 100% Bungoma 7/10 4/7

57%2/2 100%

1/1 100%

1/1 100%

2/2 100%

1/1 100%

3/6 50%

- - -

Nairobi 5/10 2/7 29%

1/1 100%

2/2 100%

2/2 100%

1/1 100%

1/1 100%

0/5 0%

- 1/1 100%

-

Nyamira 2/8 1/5 20%

0/2 0%

1/1 100%

1/1 100%

- - 0/4 0%

0/2 0%

- 1/1 100%

Nyandarua 4/8 1/5 20%

1/1 100%

2/2 100%

1/1 100%

1/1 100%

1/1 100%

0/4 0%

- 1/1 100%

0/1 0%

Stethoscope adult

Nyeri 7/10 3/6 50%

3/3 100%

1/1 100%

1/1 100%

2/2 100%

- 2/5 40%

1/1 100%

- 1/1 100%

Mean % 35% 89% 100% 100% 100% 100% 18% 50% 100% 67%

38

Bungoma 6/10 3/7 43%

2/2 100%

1/1 100%

1/1 100%

2/2 100%

1/1 100%

4/6 67%

- - -

Nairobi 6/10 3/7 43%

1/1 100%

2/2 100%

2/2 100%

1/1 100%

1/1 100%

1/5 20%

- 1/1 100%

-

Nyamira 3/8 2/5 40%

1/2 50%

0/1 0%

1/1 100%

- - 1/4 25%

1/2 50%

- 0/1 0%

Nyandarua 5/8 2/5 40%

1/1 100%

2/2 100%

1/1 100%

1/1 100%

1/1 100%

1/4 25%

- 1/1 100%

1/1 100%

Stethoscope fetal

Nyeri 7/10 3/6 50%

3/3 100%

1/1 100%

1/1 100%

2/2 100%

- 2/5 40%

1/1 100%

- 1/1 100%

Mean % 43% 90% 100% 100% 100% 100% 35% 75% 100% 67% Bungoma 6/10 4/7

57%1/2 50%

1/1 100%

1/1 100%

1/2 50%

1/1 100%

3/6 50%

- - -

Nairobi 5/10 2/7 29%

1/1 100%

2/2 100%

2/2 100%

1/1 100%

1/1 100%

0/5 0%

- 1/1 100%

-

Nyamira 1/8 1/5 20%

0/2 0%

0/1 0%

1/1 100%

- - 0/4 0%

0/2 0%

- 0/1 0%

Nyandarua 3/8 1/5 20%

1/1 100%

1/2 50%

1/1 100%

1/1 100%

1/1 100%

0/4 0%

- 1/1 100%

0/1 0%

Sphygmoma- nometer

Nyeri 7/10 3/6 50%

3/3 100%

1/1 100%

1/1 100%

2/2 100%

- 2/5 40%

1/1 100%

- 1/1 100%

Mean % 35% 60% 70% 100% 88% 100% 18% 50% 100% 33% Bungoma 8/10 5/7

71%2/2 100%

1/1 100%

1/1 100%

2/2 100%

1/1 100%

4/6 67%

- - -

Nairobi 6/10 3/7 43%

1/1 100%

2/2 100%

2/2 100%

1/1 100%

1/1 100%

1/5 20%

- 1/1 100%

-

Nyamira 5/8 2/5 40%

2/2 100%

1/1 100%

1/1 100%

- - 1/4 25%

2/2 100%

- 1/1 100%

Artery forceps, 8”

Nyandarua 5/8 2/5 40%

1/1 100%

2/2 100%

0/1 0%

1/1 100%

1/1 100%

2/4 50%

- 1/1 100%

1/1 100%

39

Nyeri 9/10 5/6 83%

3/3 100%

1/1 100%

1/1 100%

2/2 100%

- 4/5 80%

1/1 100%

- 1/1 100%

Mean % 55% 100% 100% 89% 100% 100% 48% 100% 100% 100% Bungoma 7/10 5/7

71%1/2 50%

1/1 100%

1/1 100%

1/2 50%

1/1 100%

4/6 67%

- - -

Nairobi 5/10 2/7 29%

1/1 100%

2/2 100%

2/2 100%

1/1 100%

1/1 100%

0/5 0%

- 1/1 100%

-

Nyamira 4/8 2/5 40%

1/2 50%

1/1 100%

1/1 100%

- - 1/4 20%

1/2 50%

- 1/1 100%

Nyandarua 7/8 4/5 80%

1/1 100%

2/2 100%

1/1 100%

1/1 100%

1/1 100%

3/4 75%

- 1/1 100%

1/1 100%

Mackintosh sheet

Nyeri 9/10 5/6 83%

3/3 100%

1/1 100%

1/1 100%

2/2 100%

- 4/5 80%

1/1 100%

- 1/1 100%

Mean % 61% 80% 100% 100% 88% 100% 48% 75% 100% 100% Bungoma 5/10 4/7

57%0/2 0%

1/1 100%

1/1 100%

0/2 0%

1/1 100%

3/6 50%

- - -

Nairobi 5/10 2/7 29%

1/1 100%

2/2 100%

1/2 50%

1/1 100%

1/1 100%

1/5 20%

- 1/1 100%

-

Nyamira 4/8 1/5 20%

2/2 100%

1/1 100%

0/1 0%

- - 1/4 25%

2/2 100%

- 1/1 100%

Nyandarua 4/8 1/5 20%

1/1 100%

2/2 100%

0/1 0%

1/1 100%

1/1 100%

1/4 25%

- 1/1 100%

1/1 100%

Cord scissors, 10cm

Nyeri 5/10 3/6 50%

1/3 33%

1/1 100%

1/1 100%

1/2 50%

- 2/5 40%

1/1 100%

- 1/1 100%

Mean % 35% 67% 100% 50% 63% 100% 32% 100% 100% 100% Tot. mean % 44% 78% 93% 96% 88% 95% 33% 71% 100% 81%

40

Παγε −41−

Table 3.3: Availability of Essential Equipment for Caesarian Section

All hospitals with commodity

Hospitals Item District

Total Gov Mis Priv Bungoma 4/4 1/1 100% 2/2 100% 1/1 100% Nairobi 4/4 2/2 100% 1/1 100% 1/1 100% Nyamira 1/1 1/1 100% - - Nyandarua 3/3 1/1 100% 1/1 100% 1/1 100%

Blade handle

Nyeri 3/3 1/1 100% 2/2 100% - Bungoma 4/4 1/1 100% 2/2 100% 1/1 100% Nairobi 4/4 2/2 100% 1/1 100% 1/1 100% Nyamira 1/1 1/1 100% - - Nyandarua 3/3 1/1 100% 1/1 100% 1/1 100%

Artery forceps (any)

Nyeri 3/3 1/1 100% 1/1 100% - Bungoma ¾ 1/1 100% 2/2 100% 0/1 0% Nairobi 4/4 2/2 100% 1/1 100% 1/1 100% Nyamira 1/1 1/1 100% - - Nyandarua 3/3 1/1 100% 1/1 100% 1/1 100%

Sponge forceps (any)

Nyeri 3/3 1/1 100% 2/2 100% - Bungoma 3/4 1/1 100% 2/2 100% 0/1 0% Nairobi 4/4 2/2 100% 1/1 100% 1/1 100% Nyamira 1/1 1/1 100% - - Nyandarua 3/3 1/1 100% 1/1 100% 1/1 100%

Tissue forceps (any)

Nyeri 3/3 1/1 100% 2/2 100% - Bungoma 4/4 1/1 100% 2/2 100% 1/1 100% Nairobi 2/4 1/2 50% 0/1 0% 1/1 100% Nyamira 0/1 0/1 0% - - Nyandarua 2/3 0/1 0% 1/1 100% 1/1 100%

Lagenback retractors

Nyeri 3/3 1/1 100% 2/2 100% - Bungoma 4/4 1/1 100% 2/2 100% 1/1 100% Nairobi 4/4 2/2 100% 1/1 100% 1/1 100% Nyamira 0/1 0/1 0% - - Nyandarua 2/3 0/1 0% 1/1 100% 1/1 100%

Mayo scissors (any)

Nyeri 3/3 1/1 100% 2/2 100% - Bungoma 4/4 1/1 100% 2/2 100% 1/1 100% Nairobi 4/4 2/2 100% 1/1 100% 1/1 100% Nyamira 1/1 1/1 100% - - Nyandarua 3/3 1/1 100% 1/1 100% 1/1 100%

Needle holder

Nyeri 3/3 1/1 100% 2/2 100% - Bungoma 3/4 0/1 0% 2/2 100% 1/1 100% Nairobi 4/4 2/2 100% 1/1 100% 1/1 100% Nyamira 1/1 1/1 100% - - Nyandarua 3/3 1/1 100% 1/1 100% 1/1 100%

Abdominal sheet or green towel

Nyeri 3/3 1/1 100% 2/2 100% - Total mean % 89% 97% 92%

Παγε −42−

ANNEX 4: Health Care Workers Self Reporting Practice Patterns Table4.1: Drugs Recommended to Mothers for Routine ANC Item Qualification Level of Care Hospital Health Center M/Home Dispensary

Παγε −43−

Iron Ob/Gyn 3/6 50% - - - GP 2/14 14% 0/2 0% - - CO 2/30 7% 5/30 17% 0/3 0% 0/3 0% N/midwife 12/112 11% 32/152 21% 2/16 13% 11/48 23% Nurse - 2/15 13% - 1/5 20% Midwife 1/12 8% 2/12 17% - 0/6 0% Folic Ob/Gyn 3/6 50% - - - GP 2/14 14% 0/2 0% - - CO 2/30 7% 4/30 13% 0/3 0% 0/3 0% N/midwife 11/112 10% 28/152 18% 2/16 13% 10/48 21% Nurse - 2/15 13% - 1/5 20% Midwife 0/12 0% 2/12 17% - 0/6 0% TT Ob/Gyn 3/6 50% - - - GP 2/14 14% 1/2 50% - - CO 2/30 7% 6/30 20% 0/3 0% 0/3 0% N/midwife 9/112 8% 24/152 16% 3/16 19% 5/48 10% Nurse - 1/15 7% - 1/5 20% Midwife 0/12 0% 2/12 17% - 0/6 0% Other Ob/Gyn 1/6 17% - - - GP 1/14 14% 0/2 0% - - CO 2/30 7% 1/30 3% 0/3 0% 0/3 0% N/midwife 3/112 3% 7/152 5% 0/16 0% 1/48 2% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Other 01 Ob/Gyn 0/6 0% - - - GP 1/14 7% 0/2 0% - - CO 0/30 0% 0/30 0% 0/3 0% 0/3 0% N/midwife 3/112 3% 6/152 4% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Other 02 Ob/Gyn 0/6 0% - - - GP 1/14 7% 0/2 0% - - CO 0/30 0% 0/30 0% 0/3 0% 0/3 0% N/midwife 0/112 0% 6/152 4% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Other 03 Ob/Gyn 0/6 0% - - - GP 1/14 7% 0/2 0% - - CO 0/30 0% 0/30 0% 0/3 0% 0/3 0% N/midwife 2/112 2% 2/152 1% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Mean % 10% 7% 3% 4% Table 4.2: Laboratory Tests Recommended to ANC Mothers

Παγε −44−

Item Qualification Level of Care Hospital Health Center M/Home Dispensary Blood for- grouping

Ob/Gyn

5/6 83%

-

-

-

GP 3/14 21% 1/2 50% - - CO 2/30 7% 2/30 7% 0/3 0% 0/3 0% N/midwife 13/112 2% 3/152 2% 4/16 25% 12/48 25% Nurse - 1/15 7% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Hemoglobin Ob/Gyn 6/6 100% - - - GP 4/14 29% 1/2 50% - - CO 3/30 10% 4/30 13% 0/3 0% 0/3 0% N/midwife 20/112 18% 20/152 13% 4/16 20% 6/48 13% Nurse - 2/15 13% - 0/5 0% Midwife 0/12 0% 2/12 17% - 0/6 0% Blood for malaria

Ob/Gyn

0/6 0%

-

-

-

GP 0/14 0% 0/2 0% - - CO 1/30 3% 0/30 0% 0/3 0% 0/3 0% N/midwife 3/112 3% 3/152 2% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Stool Ob/Gyn 0/6 0% - - - GP 0/14 0% 0/2 0% - - CO 1/30 3% 0/30 0% 0/3 0% 0/3 0% N/midwife 1/112 1% 1/152 1% 0/16 0% 2/48 4% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Urinalysis Ob/Gyn 4/6 67% - - - GP 5/14 36% 0/2 0% - - CO 4/30 29% 3/30 10% 0/3 0% 0/3 0% N/midwife 16/112 14% 14/152 9% 3/16 9% 3/48 6% Nurse - 1/15 7% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Other 04 Ob/Gyn 5/6 83% - - - GP 5/14 36% 1/2 50% - - CO 5/30 17% 3/30 10% 0/3 0% 0/3 0% N/midwife 18/112 16% 19/152 12% 4/16 25% 7/48 15% Nurse - 3/15 20% - 0/5 0% Midwife 0/12 0% 2/12 17% - 0/6 0% Other 05 Ob/Gyn 2/6 33% - - - GP 1/14 7% 1/2 50% - - CO 1/30 3% 0/30 0% 0/3 0% 0/3 0% N/midwife 0/112 0% 3/152 2% 1/16 6% 2/48 4% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Mean percent 18% 10% 7% 2%

Παγε −45−

Table 4.3: Drugs Used by Health Care Workers for Management of Pre-Eclampsia Item Qualification Level of Care Hospital Health Center M/Home Phenobarbitone Ob/Gyn 4/6 67% - - GP 3/14 21% 1/2 50% - CO 2/30 7% 1/30 3% 0/3 0% N/midwife 10/112 9% 5/156 3% 2/16 13% Nurse - 1/15 7% - Midwife 2/12 17% - - Methyldopa Ob/Gyn 5/6 83% - - GP 5/14 36% 0/2 0% - CO 3/30 10% 2/30 7% 0/3 0% N/midwife 17/112 15% 1/156 1% 0/16 0% Nurse - 0/15 0% - Midwife 0/12 0% - - Propranolol Ob/Gyn 0/6 0% - - GP 0/14 0% 0/2 0% - CO 0/30 0% 1/30 3% 0/3 0% N/midwife 1/112 0/156 0% 0/16 0% Nurse - 0/15 0% - Midwife 0/12 0% - - Diazepam Ob/Gyn 1/6 17% - - GP 4/14 29% 0/2 0% - CO 3/30 10% 2/30 7% 0/3 0% N/midwife 4/112 4% 5/156 3% 1/16 6% Nurse - 0/12 0% - Midwife 0/12 0% - - Hydralazine Ob/Gyn 4/6 67% - - GP 5/14 36% 0/2 0% - CO 2/30 7% 1/30 3% 0/3 0% N/midwife 6/112 5% 0/156 0% 0/16 0% Nurse - 0/12 0% - Midwife 0/12 0% - - Other 8 Ob/Gyn 3/6 50% - - GP 1/14 7% 1/2 50% - CO 5/30 17% 4/30 13% 0/3 0% N/midwife 15/112 4/156 3% 1/16 6% Nurse - 1/15 7% - Midwife 0/12 0% - - Other 9 Ob/Gyn 2/6 33% - - GP 1/14 7% 1/2 50% - CO 2/30 7% 3/30 10% 0/3 0% N/midwife 5/112 4% 2/156 1% 0/16 0% Nurse - 1/15 7% -

Παγε −46−

Midwife 0/12 0% - - Other 10 Ob/Gyn 1/6 17% - - GP 0/14 0% 0/2 0% - CO 0/30 0% 0/30 0% 0/3 0% N/midwife 1/112 1% 0/156 0% 0/16 0% Nurse - 1/15 7% - Midwife 0/12 0% - - Other 11 Ob/Gyn 1/6 17% - - GP 0/14 0% 0/2 0% - CO 0/30 0% 0/30 0% 0/3 0% N/midwife 0/112 0% 0/156 0% 0/16 0% Nurse - 0/15 0% - Midwife 0/12 0% - - Mean percent 14% 6% 1% Table 4.4: Drugs Used by Health Care Workers for the Management of Dysfunctional Labor Item Qualification Hospital Health Center Maternity Home 5% Dextrose Ob/Gyn 4/6 67% - - GP 4/14 29% 0/2 0% - CO 1/30 3% 5/30 17% 0/3 0% N/midwife 7/112 6% 8/156 5% 2/16 13% Nurse - 0/15 0% - Midwife 2/12 17% 0/12 0% - Diazepam Ob/Gyn 1/6 17% - - GP 0/14 0% 0/2 0% - CO 0/30 0% 1/30 3% 0/3 0% N/midwife 0/112 0% 0/156 0% 0/16 0% Nurse - 0/15 0% - Midwife 0/12 0% 0/12 0% - Ergometrine Ob/Gyn 3/6 50% - - GP 1/14 7% 0/2 0% - CO 1/30 3% 2/30 7% 0/3 0% N/midwife 7/112 6% 5/156 3% 1/16 6% Nurse - 0/15 0% - Midwife 1/12 8% 0/12 0% - Oxytocin Ob/Gyn 4/6 67% - - GP 5/14 36% 0/2 0% - CO 1/30 3% 0/30 0% 0/3 0% N/midwife 6/112 5% 0/156 0% 1/16 6% Nurse - 0/15 0% - Midwife 1/12 8% 0/12 0% - Other 16 Ob/Gyn 5/6 83% - - GP 4/14 29% - -

Παγε −47−

CO 0/30 0% 3/30 10% 0/3 0% N/midwife 12/112 19% 16/156 10% 2/16 13% Nurse - 0/15 0% - Midwife 1/12 8% 1/12 8% - Other 17 Ob/Gyn 2/6 33% - - GP 1/14 7% 0/2 0% - CO 0/30 0% 2/30 7% 0/3 0% N/midwife 9/112 8% 5/156 3% 2/16 13% Nurse - 0/15 0% - Midwife 0/12 0% 0/12 0% - Other 18 Ob/Gyn 2/6 33% - - GP 1/14 7% 0/2 0% - CO 0/30 0% 1/30 3% 0/3 0% N/midwife 3/112 3% 3/156 2% 0/16 0% Nurse - 0/15 0% - Midwife 0/12 0% 0/12 0% - Other 19 Ob/Gyn 1/6 17% - - GP 1/14 7% 0/2 0% - CO 0/30 0% 0/30 0% 0/3 0% N/midwife 1/112 1% 0/156 0% 0/16 0% Nurse - 0/15 0% - Midwife 0/12 0% 0/12 0% - Other 20 Ob/Gyn 1/6 17% - - GP 0/14 0% 0/2 0% - CO 0/30 0% 0/30 0% 0/3 0% N/midwife 0/112 0% 0/156 0% 0/16 0% Nurse - 0/15 0% - Midwife 0/12 0% 0/12 0% - Mean percent 14% 1% 3% Table 4.5: Drugs Used by Health Care Workers for the Management of Normal Delivery Item Qualification Hospital Health Center Maternity

Home Dispensary

Diazepam Ob/Gyn 1/6 17% - - - GP 0/14 0% 0/2 0% - - CO 0/30 0% 0/30 0% 0/3 0% 0/3 0% N/midwife 0/112 0% 0/156 0% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Ergometrine Ob/Gyn 6/6 100% - - - GP 3/14

21% 1/2 50% - -

Παγε −48−

CO 2/30 7%

4/30 13% 0/3 0% 0/3 0%

N/midwife 18/112 16% 25/156 16% 4/16 25% 4/48 8% Nurse - 2/15 13% - 0/5 0% Midwife 2/12 17% 1/12 8% - 0/6 0% paracetamol Ob/Gyn 2/6 33% - - - GP 2/14 14% 1/2 50% - - CO 0/30 0% 1/30 3% 0/3 0% 0/3 0% N/midwife 5/112 4% 4/156 3% 0/16 0% 3/48 6% Nurse - 1/15 7% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Vitamin K Ob/Gyn 1/6 17% - - - GP 0/14 0% 0/2 0% - - CO 0/30 0% 0/30 0% 0/3 0% 0/3 0% N/midwife 0/112 0% 0/156 0% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Other 24 Ob/Gyn 3/6 50% - - - GP 4/14 29% ½ 50% - - CO 0/30 0% 0/30 0% 0/3 0% 0/3 0% N/midwife 8/112 7% 5/156 3% 2/16 13% 5/48 10% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Other 25 Ob/Gyn 1/6 17% - - - GP 0/14 0% 0/2 0% - - CO 0/30 0% 2/30 7% 0/3 0% 0/3 0% N/midwife 2/112 2% 2/156 1% 1/16 6% 2/48 4% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0 % - 0/6 0% Other 26 Ob/Gyn 0/6 0% - - - GP 0/14 0% 0/2 0% - - CO 0/30 0% 1/30 3% 0/3 0% 0/3 0% N/midwife 1/112 1% 0/156 0% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Mean percent 10% 6% 3% 1% Table 4.6: Drugs Used by Health Care Workers for the Management of Hemorrhage Item Qualification Hospital Health Center Maternity

Home Dispensary

Ergometrine Ob/Gyn 3/6 50% - - - GP 2/14 29% 1/2 50% - - CO 2/30 7% 3/30 10% 0/3 0% 0/3 0% N/midwife 9/112 8% 8/156 5% 3/16 19% 2/48 4%

Παγε −49−

Nurse - 0/15 0% - 0/5 0%

Midwife 2/12 17% 0/12 0% - 0/6 0% Oxytocin Ob/Gyn 2/6 33% - - - GP 1/14 7% 0/2 0% - - CO 0/30 0% 0/30 0% 0/3 0% 0/3 0% N/midwife 1/112 1% 0/156 0% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Transfusion Ob/Gyn 4/6 67% - - - GP 0/14 0% 0/2 0% - - CO 1/30 3% 0/30 0% 0/3 0% 0/3 0% N/midwife 4/112 4% 0/156 0% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% IV Fluid Ob/Gyn 5/6 83% - - - GP 4/14 29% 0/2 0% - - CO 0/30 0% 2/30 17% 0/3 0% 0/3 0% N/midwife 9/112 8% 3/156 2% 1/16 6% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 2/12 17% 0/12 0% - 0/6 0% Other 32 Ob/Gyn 5/6 83% - - - GP 7/14 50% ½ 50% - - CO 6/30 20% 6/30 20% 0/3 0% 0/3 0% N/midwife 16/112 14% 7/156 4% 3/16 19% 4/48 8% Nurse - 0/15 0% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Other 33 Ob/Gyn 4/6 67% - - - GP 6/14 43% 1/2 50% - - CO 5/30 17% 2/30 7% 0/3 0% 0/3 0% N/midwife 9/112 8% 3/156 19% 2/16 13% 3/48 6% Nurse - 0/15 0% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Other 34 Ob/Gyn 4/6 67% - - - GP 4/14 29% 0/2 0% - - CO 4/30 13% 2/30 7% 0/3 0% 0/3 0% N/midwife 6/112 5% 2/156 1% 0/16 0% 2/48 4% Nurse - 0/15 0% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Other 35 Ob/Gyn 2/6 33% - - - GP 3/14 21% 0/2 0% - - CO 2/30 7% 1/30 3% 0/3 0% 0/3 0% N/midwife 3/112 3% 2/156 2% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Other 36 Ob/Gyn 1/6 17% - - - GP 0/14 0% 0/2 0% - -

Παγε −50−

CO 1/30 3% 1/30 3% 0/3 0% 0/3 0% N/midwife 2/112 2% 2/156 1% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Mean percent 20% 6% 3% 1% Table 4.7: Drugs Used by Health Care Workers for Caesarian Section Item Qualification Hospital Health Center Atropine Ob/Gyn 3/6 50% - GP 6/14 43% 1/2 50% CO 1/30 3% 0/30 0% Dextrose 5% Ob/Gyn 4/6 67% - GP 2/14 14% 1/2 50% CO 1/30 3% 0/30 0% Neostigmine Ob/Gyn 1/6 17% - GP 3/14 21% 0/2 0% CO 1/30 3% 0/30 0% Normal saline Ob/Gyn 3/6 50% - GP 2/14 14% 1/2 50% CO 1/30 3% 0/30 0% Oxytocin Ob/Gyn 2/6 33% - GP 1/14 7% 0/2 0% CO 0/30 0% 0/30 0% Paracetamol Ob/Gyn 1/6 17% - GP 2/14 14% 0/2 0% CO 0/30 0% 0/30 0% Pethidine Ob/Gyn 3/6 50% - GP 3/14 21% 0/2 0% CO 0/30 0% 0/30 0% Suxamethonium Ob/Gyn 3/6 50% - GP 2/14 14% 0/2 0% CO 1/30 3% 0/30 0% Thiopentine Ob/Gyn 2/6 33% - GP 3/14 21% 0/2 0% CO 1/30 3% 0/30 0% Other 40 Ob/Gyn 4/6 67% - GP 7/14 50% 1/2 50% CO 1/30 3% 0/30 0% Other 41 Ob/Gyn 4/6 67% - GP 6/14 43% 1/2 50% CO 1/30 3% 0/30 0% Other 42 Ob/Gyn 3/6 50% - GP 4/14 14% 1/2 50% CO 1/30 3% 0/30 0%

Παγε −51−

Other 43 Ob/Gyn 1/6 17% - GP 2/14 14% 1/2 50% CO 1/30 3% 0/30 0% Other 44 Ob/Gyn 1/6 17% - GP 0/14 0% 0/2 0% CO 1/30 3% 0/30 0% 21% 12% Table 4.8: Drugs Used by Health Care Workers for Management of Puerperal Sepsis Item Qualification Hospital Health

Center Maternity Home

Dispensary

Amoxicillin Ob/Gyn 1/6 17% - - - GP 2/14 14% 0/2 0% - - CO 3/30 10% 0/30 0% 0/3 0% 0/3 0% N/midwife 3/112 3% 11/156 7% 1/16 6% 2/48 4% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Ampicillin Ob/Gyn 2/6 33% - - - GP 2/14 14% 0/2 0% - - CO 2/30 7% 3/30 3% 0/3 0% 0/3 0% N/midwife 5/112 4% 2/156 1% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Dextrose 5% Ob/Gyn 1/6 17% - - - GP 1/14 7% 0/2 0% - - CO 0/30 0% 0/30 0% 0/3 0% 0/3 0% N/midwife 3/112 3% 0/156 0% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Gentamycin Ob/Gyn 2/6 33% - - - GP 6/14 43% 0/2 0% - - CO 3/30 10% 1/30 3% 0/3 0% 0/3 0% N/midwife 6/112 5% 1/156 1% 0/16 0% 2/48 4% Nurse - 0/15 0% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Metronidazole Ob/Gyn 2/6 33% - - - GP 7/14 50% ½ 50% - - CO 7/30 23% 8/30 27% 0/3 0% 0/3 0% N/midwife 7/112 6% 11/156 7% 0/16 0% 2/48 4% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Paracetamol Ob/Gyn 3/6 50% - - - GP 2/14 14% 0/2 0% - -

Παγε −52−

CO 1/30 3% 2/30 7% 0/3 0% 0/3 0% N/midwife 5/112 4% 10/156 6% 1/16 6% 4/48 8% Nurse - 0/15 0% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Other 48 Ob/Gyn 5/6 83% - - - GP 6/14 43% 1/2 0% - - CO 8/30 27% 7/30 23% 0/3 0% 0/3 0% N/midwife 12/112 11% 16/156 10% 2/16 13% 8/48 17% Nurse - 0/15 0% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Other 49 Ob/Gyn 5/6 83% - - - GP 4/14 29% 1/2 50% - - CO 5/30 17% 6/30 20% 0/3 0% 0/3 0% N/midwife 11/112 10% 13/156 8% 2/16 13% 4/48 8% Nurse - 0/15 0% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Other 50 Ob/Gyn 5/6 83% - - - GP 2/14 14% 1/2 50% - - CO 5/30 17% 5/30 17% 0/3 0% 0/3 0% N/midwife 5/112 4% 7/156 4% 2/16 13% 2/48 4% Nurse - 0/15 0% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Mean percent 19% 7% 3% 1% Table 4.9: Drugs Used by Health Care Workers for Management of UTI Item Qualification Hospital Health

Center Maternity Home

Dispensary

Ampicillin Ob/Gyn 1/6 17% - - - GP 1/14 7% 0/2 0% - - CO 0/30 0% 1/30 3% 0/3 0% 0/3 0% N/midwife 2/112 2% 3/156 2% 1/16 6% 3/48 6% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Amoxicillin Ob/Gyn 0/6 0% - - - GP 3/14 21% 0/2 0% - CO 4/30 13% 3/30 3% 0/3 0% 1/3 33% N/midwife 9/112 8% 4/156 3% 1/16 6% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Cotrimoxazole Ob/Gyn 0/6 0% - - - GP 1/14 7% 0/2 0% - - CO 0/30 0% 0/30 0% 0/3 0% 0/3 0% N/midwife 2/112 2% 2/156 1% 0/16 0% 4/48 8% Nurse - 1/15 7% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0%

Παγε −53−

Erythromycin Ob/Gyn 0/6 0% - - - GP 1/14 7% 0/2 0% - - CO 1/30 3% 0/30 0% 0/3 0% 0/3 0% N/midwife 1/112 1% 5/156 3% 0/16 0% 2/48 4% Nurse - 1/15 7% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Metronidazole Ob/Gyn 0/6 0% - - - GP 2/14 14% ½ 50% - - CO 1/30 3% 2/30 7% 0/3 0% 0/3 0% N/midwife 8/112 7% 11/156 7% 0/16 0% 4/48 8% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Nitrofuratoin Ob/Gyn 4/6 67% - - - GP 2/14 14% 0/2 0% - - CO 3/30 10% 0/30 0% 0/3 0% 0/3 0% N/midwife 7/112 6% 4/156 3% 0/16 0% 1/48 2% Nurse - 1/15 7% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Other 56 Ob/Gyn 5/6 83% - - - GP 6/14 43% 1/2 50% - - CO 9/30 10% 10/30 33% 0/3 0% 1/3 33% N/midwife 23/112 21% 34/156 22% 4/16 25% 7/48 15% Nurse - 2/15 13% - 1/5 20% Midwife 1/12 8% 2/12 17% - 1/6 17% Other 57 Ob/Gyn 3/6 50% - - - GP 5/14 36% 1/2 50% - - CO 5/30 17% 10/30 33% 0/3 0% 0/3 0% N/midwife 13/112 12% 22/156 14% 3/16 19% 5/48 10% Nurse - 1/15 7% - 0/5 0% Midwife 1/12 8% 2/12 17% - 1/6 17% Other 58 Ob/Gyn 2/6 33% - - - GP 4/14 29% 1/2 50% - - CO 1/30 3% 5/30 17% 0/3 0% 0/3 0% N/midwife 6/112 5% 10/156 6% 1/16 6% 0/48 0% Nurse - 1/15 7% - 0/5 0% Midwife 1/12 8% 1/12 8% - 0/6 0% Other 59 Ob/Gyn 1/6 7% - - - GP 3/14 21% 0/2 0% - - CO 0/30 0% 2/30 7% 0/3 0% 0/3 0% N/midwife 4/112 4% 5/156 3% 1/16 6% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Mean percent 12% 8% 3% 4 % Table 4.10: Drugs Used by Health Care Workers for Management of GUD

Παγε −54−

Item Qualification Hospital Health

Center Maternity Home

Dispensary

Amoxicillin Ob/Gyn 1/6 17% - - - GP 0/14 0% 0/2 0% - - CO 0/30 0% 0/30 0% 0/3 0% 1/3 3% N/midwife 1/112 1% 0/156 0% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 1/6 17% BenzathinePen. Ob/Gyn 2/6 33% - - - GP 2/14 14% 1/2 50% - CO 2/30 7% 7/30 23% 0/3 0% 1/3 33% N/midwife 4/112 4% 9/156 6% 1/16 6% 2/48 4% Nurse - 1/15 7% - 0/5 0% Midwife 0/12 0% 0/12 0% - 1/6 17% Ciprofloxacin Ob/Gyn 0/6 0% - - - GP 0/14 0% 0/2 0% - - CO 0/30 0% 0/30 0% 0/3 0% 0/3 0% N/midwife 0/112 0% 0/156 0% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Doxycycline Ob/Gyn 1/6 17% - - - GP 0/14 0% 0/2 0% - - CO 1/30 3% 1/30 3% 0/3 0% 0/3 0% N/midwife 0/112 0% 1/156 1% 0/16 0% 1/48 2% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Erythromycin Ob/Gyn 1/6 17% - - - GP 1/14 7% ½ 50% - - CO 4/30 13% 6/30 20% 0/3 0% 0/3 0% N/midwife 6/112 5% 9/156 6% 1/16 6% 2/48 4% Nurse - 1/15 7% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Norfloxacin Ob/Gyn 1/6 17% - - - GP 0/14 0% 0/2 0% - - CO 0/30 0% 0/30 0% 0/3 0% 0/3 0% N/midwife 0/112 0% 2/156 1% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Other 64 Ob/Gyn 5/6 83% - - - GP 2/14 14% 1/2 0% - - CO 6/30 20% 6/30 20% 0/3 0% 1/3 33% N/midwife 7/112 6% 11/156 7% 1/16 6% 7/48 15% Nurse - 1/15 7% - 0/5 0% Midwife 0/12 0% 1/12 8% - 1/6 17% Other 65 Ob/Gyn 5/6 83% - - -

Παγε −55−

GP 0/14 0% 0/2 0% - - CO 4/30 13% 4/30 3% 0/3 0% 0/3 0% N/midwife 3/112 3% 4/156 3% 0/16 0% 6/48 13% Nurse - 1/15 7% - 0/5 0% Midwife 0/12 0% 1/12 8% - 0/6 0% Other 66 Ob/Gyn 2/6 33% - - - GP 0/14 0% 0/2 50% - - CO 2/30 7% 0/30 0% 0/3 0% 0/3 0% N/midwife 2/112 2% 2/156 1% 0/16 0% 3/48 6% Nurse - 1/15 7% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Mean percent 9% 7% 1% 5% Table 4.11: Drugs Used by Heath Care Workers for Management of Gonorrhea Item Qualification Hospital Health

Center Maternity Home

Dispensary

Amoxicillin Ob/Gyn 1/6 17% - - - GP 0/14 0% 0/2 0% - - CO 2/30 7% 0/30 0% 0/3 0% 1/3 3% N/midwife 6/112 5% 3/156 2% 2/16 1% 1/48 2% Nurse - 0/15 0% - 0/5 0% Midwife 1/12 8% 0/12 0% - 1/6 17% Augmentin Ob/Gyn 1/6 17% - - - GP 0/14 0% 0/2 0% - CO 0/30 0% 0/30 0% 0/3 0% 0/3 0% N/midwife 2/112 2% 0/156 0% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Doxycycline Ob/Gyn 1/6 17% - - - GP 1/14 7% 0/2 0% - - CO 4/30 13% 4/30 13% 0/3 0% 0/3 0% N/midwife 2/112 2% 11/156 7% 1/16 6% 1/48 2% Nurse - 1/15 7% - 0/5 0% Midwife 0/12 0% 0/12 0% - 1/6 17% Erythromycin Ob/Gyn 1/6 17% - - - GP 0/14 0% 0/2 0% - - CO 0/30 0% 0/30 0% 0/3 0% 0/3 0% N/midwife 2/112 2% 3/156 2% 0/16 0% 1/48 2% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Norfloxacin Ob/Gyn 0/6 0% - - - GP 1/14 7% 0/2 0% - -

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CO 4/30 13% 4/30 13% 0/3 0% 0/3 0% N/midwife 2/112 2% 9/156 6% 1/16 6% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Probenecid Ob/Gyn 1/6 17% - - - GP 0/14 0% 0/2 0% - - CO 1/30 3% 0/30 0% 0/3 0% 0/3 0% N/midwife 2/112 2% 0/156 0% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Other 72 Ob/Gyn 5/6 83% - - - GP 6/14 43% 1/2 50% - - CO 9/30 30% 9/30 30% 0/3 0% 1/3 33% N/midwife 22/112 20% 33/156 21% 4/16 25% 11/48 23% Nurse - 2/15 13% - 1/5 20% Midwife 2/12 17% 1/12 8% - 1/6 17% Other 73 Ob/Gyn 4/6 67% - - - GP 4/14 29% 1/2 50% - - CO 7/30 23% 7/30 23% 0/3 0% 1/3 33% N/midwife 20/112 18% 19/156 12% 2/16 13% 9/48 19% Nurse - 2/15 13% - 1/5 20% Midwife 1/12 8% 0/12 0% - 0/6 0% Other 74 Ob/Gyn 2/6 33% - - - GP 4/14 29% 0/2 50% - - CO 5/30 17% 4/30 13% 0/3 0% 0/3 0% N/midwife 13/112 12% 11/156 7% 2/16 13% 4/48 8% Nurse - 1/15 7% - 1/5 20% Midwife 1/12 8% 0/12 0% - 0/6 0% Other 75 Ob/Gyn 0/6 0% - - - GP 2/14 14% 0/2 50% - - CO 1/30 3% 1/30 3% 0/3 0% 0/3 0% N/midwife 7/112 6% 7/156 4% 1/16 6% 3/48 6% Nurse - 0/15 0% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Mean percent 13% 8% 4% 6% Table 4.12: Drugs Used by Health Care Workers for the Management of Acute Pelvic Inflammatory Disease (PID) Item Qualification Hospital Health

Center Maternity Home

Dispensary

Amoxicillin Ob/Gyn 2/6 33% - - - GP 1/14 7% 0/2 0% - - CO 1/30 3% 1/30 3% 0/3 0% 0/3 0% N/midwife 6/112 5% 7/156 4% 0/16 0% 1/48 2%

Παγε −57−

Nurse - 1/15 7% - 0/5 0% Midwife 1/12 8% 0/12 0% - 1/6 7% Doxycycline Ob/Gyn 2/6 33% - - - GP 1/14 7% 0/2 0% - CO 5/30 17% 8/30 27% 0/3 0% 0/3 0% N/midwife 5/112 4% 7/156 4% 1/16 6% 3/48 6% Nurse - 2/15 13% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Erythromycin Ob/Gyn 0/6 0% - - - GP 1/14 7% 0/2 0% - - CO 3/30 10% 2/30 7% 0/3 0% 0/3 0% N/midwife 1/112 1% 7/156 4% 0/16 0% 1/48 2% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Metronidazole Ob/Gyn 3/6 50% - - - GP 3/14 21% 1/2 50% - - CO 8/30 27% 9/30 30% 1/3 33% 1/3 33% N/midwife 11/112 10% 17/156 11% 1/16 6% 4/48 8% Nurse - 1/15 7% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Norfloxacin Ob/Gyn 1/6 17% - - - GP 1/14 7% 0/2 0% - - CO 4/30 13% 8/30 27% 0/3 0% 0/3 0% N/midwife 3/112 3% 8/156 5% 1/16 6% 1/48 2% Nurse - 1/15 7% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Other 80 Ob/Gyn 5/6 83% - - - GP 4/14 29% ½ 50% - - CO 10/30 33% 7/30 23% 1/3 3% 1/3 3% N/midwife 14/112 13% 25/156 16% 2/16 13% 7/48 15% Nurse - 2/15 13% - 0/5 0% Midwife 1/12 8% 1/12 8% - 1/6 17% Other 81 Ob/Gyn 3/6 50% - - - GP 3/14 21% 1/2 50% - - CO 9/30 30% 4/30 13% 0/3 0% 1/3 33% N/midwife 11/112 10% 13/156 8% 2/16 13% 7/48 15% Nurse - 1/15 7% - 0/5 0% Midwife 1/12 8% 0/12 0% - 1/6 17% Other 82 Ob/Gyn 3/6 50% - - - GP 2/14 14% ½ 50% - - CO 7/30 23% 1/30 3% 0/3 0% 1/3 23% N/midwife 7/112 6% 8/156 5% 2/16 13% 5/48 10% Nurse - 0/15 0% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Other 83 Ob/Gyn 1/6 17% - - - GP 2/14 14% 0/2 0% - - CO 3/30 10% 1/30 3% 0/3 0% 0/3 0%

Παγε −58−

N/midwife 4/112 4% 4/156 3% 1/16 6% 2/48 4% Nurse - 0/15 0% - 0/5 0% Midwife 1/12 8% 0/12 0% - 0/6 0% Other 84 Ob/Gyn 1/6 17% - - - GP 1/14 7% 0/2 0% - - CO 0/30 0% 1/30 3% 0/3 0% 0/3 0% N/midwife 2/112 2% 1/156 1% 0/16 0% 0/48 0% Nurse - 0/15 0% - 0/5 0% Midwife 0/12 0% 0/12 0% - 0/6 0% Mean percent 15% 9% 5% 5%

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ANNEX 5: Survey Forms

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REPRODUCTIVE HEALTH COMMODITIES STUDY

HEALTH FACILITY SURVEY FORM

District:

Health Facility:

Facility Type: (PH=provincial hospital;

DH=district hospital; OH=Other hospital, MH=maternity or nursing home; HC=health center;

DI=dispensary)

Facility Administration:(G=government;

M=mission, N=Other NGO, P=owned by company or private individual)

Date:

Data collector:

FACILITY AND STAFFING

The study team should hold an introductory meeting with the key members of the hospital staff (medical superintendent, hospital matron, chief supplies officer, chief pharmacist) or with the medical and nursing officers in charge of a lower level facility. At this briefing, explain the purpose of the survey, and ensure the staff that its purpose is not to rate their facility. After completing the briefing, explain that you would like to ask some general questions about the facility, its staff, the reproductive health services offered, and recent utilization. The staff may need to assemble the data for Questions 1-16 from a variety of sources.

1. What is the catchment population of this facility?

Enter population; if not known, enter 0

2. Have you calculated the antenatal care coverage rate for this facility? If yes,

what is this rate? Enter percent; if not known, enter 0

3. Have you calculated the percent of deliveries in yourcatchment area that take

place in this facility? If yes, what is this percent? Enter percent; if not known, enter 0

4. What is the total number of beds in this facility (including maternity)?

5. How many of those beds are regularly used for the following services?

Enter number of beds, or 0 if no beds are assigned for this purpose

Number of beds

a. for labor and waiting before delivery

b. for delivery

c. for post-natal stay

6. What is the average occupancy rate of the beds used for post-natal stay?

Enter percent

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7. What is the total number of health providers currently working at this facility

who regularly provide care for women during pregnancy or delivery?

Number of staff

a. OB/Gyn Specialists

b. GPs or other medical specialties

c. Clinical Officers

d. Nurses with midwifery training

e. Nurses without midwifery experience

f. Midwives

SERVICES

8. Which of the following services are provided at this facility?

Read and ask about each service separately

check box :

a. Antenatal care

9 1 Yes

9 0 No

b. Treatment of STDs

9 1 Yes

9 0 No

c. Normal delivery care

9 1 Yes

9 0 No

d. Manual vacuum aspiration (MVA)

9 1 Yes

9 0 No

9. Which of the following complications can be managed at this facility?

Read and ask about each complication separately

check box :

a. Care for pre-eclampsia

9 1 Yes

9 0 No

b. Care for eclampsia

9 1 Yes

9 0 No

c. Care for obstructed or prolonged labor

9 1 Yes

9 0 No

d. Care for maternal hemorrhage

9 1 Yes

9 0 No

e. Caesarian section

9 1 Yes

9 0 No

f. Management of abortion complications/incomplete delivery

9 1 Yes

9 0 No

g. Care for maternal sepsis

9 1 Yes

9 0 No

If this facility does not perform Caesarian sections, skip to Q. 12

10. How many surgical theaters in this facility are used on a regular basis for

performing Caesarian sections?

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11. How many doctors regularly perform Caesarian sections in this facility?

12. Which of the following laboratory tests are currently performed at this facility?

Read and ask about each lab test separately

check box :

a. Malaria smear

9 1 Yes

9 0 No

b. Urine analysis for glucose and protein

9 1 Yes

9 0 No

c. Urine culture and sensitivity

9 1 Yes

9 0 No

d. Hemoglobin

9 1 Yes

9 0 No

e. Blood group typing and RH cross reactivity

9 1 Yes

9 0 No

f. Blood culture and sensitivity

9 1 Yes

9 0 No

f. Stool for ova and parasites

9 1 Yes

9 0 No

13. Are maternal and child services integrated with other services (antenatal,

postpartum, family planning services all provided on a daily basis)?

9 1 Yes

9 0 No

14. Do you routinely refer high-risk antenatal mothers to another facility?

9 1 Yes

9 0 No

15. Do you often refer complications to another facility?

9 1 Yes

9 0 No

16. How many hours does it usually take to travel by car to the nearest referral

facility? Enter number of hours

Request to see the service utilization records for the previous calendar year (based on regular records, logs or standard forms, for example, the MOH Workload Forms, Inpatient Morbidity Forms, or Outpatient Morbidity Forms). Record the total number of patient consultations during that year for the each following categories of reproductive health services for which data are available. If annual data are not available for a given condition, enter N/A. If no data from the previous year are available, record the number of consultations per month for each condition during the previous three months for which data are available. Enter N/A if there are no data.

Number of monthly consultations [Enter month for which data apply]

17. Consultations for RH Problems

Total consultations reported during the previous calendar

year

Antenatal care

Deliveries

Caesarian sections

UTI

Syphilis (or GUD)

Gonorrhea/chlamydia (or vaginal discharge)

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Number of monthly consultations

[Enter month for which data apply]

17. Consultations for RH Problems

Total consultations reported during the previous calendar

year

PID

INFRASTRUCTURE AND EQUIPMENT

Province:

District:

Health Facility:

Facility Type: (PH=provincial hospital; DH=district hospital; OH=Other

hospital, MH=maternity or nursing home; HC=health center; DI=dispensary)

Date:

Data collector:

Explain that you would like you to see the facilities and equipment used here in providing MCH services. Visit all MCH areas, delivery rooms, maternity theaters, and the laboratory to observe the presence and condition of the following infrastructure and equipment. Code each item of physical infrastructure based on its condition on the day of the visit:

0 = Not available 1 = Available but not satisfactory 2 = Available and satisfactory

Code as not satisfactory items which in your opinion are not functional, missing parts, unhygienic, or otherwise sub-standard.

18. Physical Infrastructure

0 = Not available 1 = Available but not satisfactory 2 = Available and satisfactory

Refrigerator

Functioning laboratory facilities: including microscope, centrifuge, and clean water supply

Functioning delivery room: including bed, linen, lighting, and clean water supply

Functioning operating theater: including operating table, shadowless lamp, trolley, suction apparatus, anesthesia equipment, oxygen, nitrous oxide, and emergency light

Next, visit the MCH antenatal clinic in this facility. Count how many of the following items of basic medical equipment are present, and evaluate their condition. Enter ticks for each item in the appropriate box as you proceed, and sum up the totals for each item at the end.

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Indicate in the appropriate column the number of items that are present and in satisfactory condition, and the number that are present but not satisfactory. Code as not satisfactory items which are not functional, missing parts, unhygienic, or otherwise sub-standard. After completing all equipment inventories that apply to this facility, ask the administrator to see medical equipment purchasing records for the previous year. If purchasing records are not kept in the health facility, there may be copies in the District Office. For any equipment item purchased during the previous year, record the most recent purchase price. Prices should NOT be estimated, but based on actual recorded values. If no purchases were made, or records cannot be located, leave items blank.

FOR ALL FACILITIES:

19. Basic MCH Equipment

Number available and satisfactory

Number available and not satisfactory

Last purchase

price

gestational wheel

scale, adult

scale, baby

stethoscope

stethoscope, fetal

sphygmomanometer

tape measure

thermometer

Next, if this facility handles normal births, visit the labor and delivery area and the maternity ward. Count the following items of equipment needed for normal delivery and evaluate their condition. Enter ticks as you proceed, and sum up the totals for each item at the end. Indicate in the appropriate column the number of items that are present and in satisfactory condition, and the number that are present but not satisfactory. Code as not satisfactory items which are not functional, missing parts, unhygienic, or otherwise sub-standard.

FOR ALL FACILITIES PERFORMING NORMAL DELIVERIES: 20. Equipment for Normal Delivery

Number available and

satisfactory

Number available and

not satisfactory

Last purchase

price

airway

ambu bag, baby

blanket, baby

bowl, kidney stainless steel 10"

bowl 36"

forceps, artery 8" straight

gestational wheel

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FOR ALL FACILITIES PERFORMING NORMAL DELIVERIES: 20. Equipment for Normal Delivery

Number available and

satisfactory

Number available and

not satisfactory

Last purchase

price

needle holder 7" scale, adult

scale, baby

scissors, cord 10 cm

scissors, episiotomy 12.5 cm

scrub brush, surgeon's

sheet, Macintosh

speculum, vaginal

sphygmomanometer

stethoscope

stethoscope, fetal

suction machine

tape measure

thermometer

tongue blade

towel, baby drying

Finally, if this facility handles obstetric surgery, visit the maternity theater. Be sure to check for equipment that may have been sent to the Central Sterilizing Supply Unit for sterilization. Count the following items of surgical equipment and evaluate their condition. Enter ticks for each item in the appropriate box as you proceed, and sum up the totals for each item at the end. Indicate in the appropriate column the number of items that are present and in satisfactory condition, and the number that are present but not satisfactory. Code as not satisfactory items which are not functional, missing parts, unhygienic, or otherwise sub-standard.

FOR ALL HOSPITALS PERFORMING OBSTETRIC SURGERY: 21. Hospital Surgical Equipment

Number available and

satisfactory

Number available and

not satisfactory

Last

purchase price

airway, sm, med, lg

blade handle (bard parker #4)

boots, non static gum (pair)

bowl, lg stainless steel

cannula, Carmans IPAS double valve

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FOR ALL HOSPITALS PERFORMING OBSTETRIC SURGERY: 21. Hospital Surgical Equipment

Number available and

satisfactory

Number available and

not satisfactory

Last

purchase price

cannula, Carmans IPAS single valve

cannula, flexible sz 10

cannula, flexible sz 4

cannula, flexible sz 5

cannula, flexible sz 6

cannula, flexible sz 7

cannula, flexible sz 9

cannula, flexible sz8

currette, uterine double ended 7"

currette, uterine sharp ended 9"

dilator, Haggar's uterine (one set, size 3-16)

forceps, artery 8" straight

forceps, artery Chances (COF) 7"

forceps, artery Dunhill (COF) 5"

forceps, artery Spencer Wells 7"

forceps, artery fine

forceps, dissecting 7" toothed Lanes

forceps, dissecting Trevors 7" nontoothed

forceps, dissecting, nontoothed, fine

forceps, dissecting, nontoothed, lg

forceps, dissecting, toothed, fine

forceps, dissecting, toothed, lg

forceps, double toothed teneculum

forceps, obstetric

forceps, ovum (9") medium 2 med, 1lg

forceps, sponge holding

forceps, sponge holding (Lamley or Forester) 9"

forceps, tissue green armetage

forceps, tissue, Allis

forceps, valsellum Trevors 9"

forceps, valsellum Trevors 9"

galli pot 6"

handle, BardParker size 3

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FOR ALL HOSPITALS PERFORMING OBSTETRIC SURGERY: 21. Hospital Surgical Equipment

Number available and

satisfactory

Number available and

not satisfactory

Last

purchase price

kidney dish, lg kidney dish, sm

laryngoscope

mayo 6 1/2" straight

mayo 7 1/2" curved

needle holder, long

pack, lg green

retractor, doyens

retractor, lagenback med

scissors, mayo curved

scissors, straight

scrub brush

sheet, plastic Macintosh

speculum, Auvard 9"

speculum, Simms 9" 1 lg, 1 sm

speculum, Simms 9" 1 lg, 1 sm

sponge holder

suction end (metal)

surgical gown

towel clip

towel, abdominal sheet

towel, green

tray, placenta

trousers, surgical

uterine sound graduated 12" double ended

uterine sound graduated 12" single ended

vacuum extractor, manual

vest, surgical

yankaur

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INVENTORY OF COMMODITIES

Province:

District:

Health Facility:

Facility Type: (PH=provincial hospital; DH=district hospital; OH=Other

hospital, MH=maternity or nursing home; HC=health center; DI=dispensary)

Date:

Data collector:

Visit the pharmacy or supply areas where drug and medical supply stock records are kept. If stock records exist, record the quantity currently in stock from stock records for each drug and medical supply item. If there are drug kits or bulk shipments unopened in the facility stores, be sure to count the quantities available in both the recorded quantity and the physical count. Enter the strength for each drug found (e.g., 250 mg or 30 mg/ml). If more than one strength is found, count the one with the highest stock level. CONSIDER ANY BRAND NAME ITEMS TO BE THE SAME AS THEIR GENERIC EQUIVALENTS. Next, physically count and record the quantity actually in stock. For tablets or capsules, record the quantity to the nearest half bottle. After completing the inventory, ask the pharmacist or facility administrator to see drug and medical supply equipment purchasing records for the previous year. If purchasing records are not kept in the health facility, there may be copies in the District Office. For any drug or medical supply item purchased during the previous year, record the most recent purchase price. Prices should NOT be estimated, but based on actual recorded values. If no purchases were made, or records cannot be located, leave items blank.

FOR ALL FACILITIES: 22. Inventory of Basic Drugs

Name

Form

Strength?

Recorded Quantity

Physical

Count

Last Purchase

Price

amoxycillin

cap

augmentin

tablet

benzathine penicillin

vial

chloroquine phosphate

tablet

doxycycline

cap

erythromycin

tablet

ferrous sulphate

tablet

folic acid

tablet

mebendazole

tablet

metronidazole

tablet

norfloxacin

tablet

paracetamol

tablet

probenecid

tablet

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FOR ALL FACILITIES PERFORMING NORMAL DELIVERIES: 23. Inventory of Additional Drugs for Delivery

Name

Form

Strength?

Recorded Quantity

Physical

Count

Last Purchase

Price

cotrimoxazole

tablet

ergometrine

amp

lidocaine

ml

normal saline

bottle

oxytocin

amp

tetracycline 1% ointment

tube

FOR HOSPITALS OFFERING REFERRAL CARE OR OBSTETRIC SURGERY: 24. Inventory of Referral Drugs

Name

Form

Strength?

Recorded Quantity

Physical

Count

Last Purchase

Price

amikacin

vial

ampicillin

cap

ampicillin

vial

atropine

amp

ciprofloxacin

tablet

cloxacillin

cap

crystalline penicillin

vial

dextrose 5%

bottle

dextrose and normal saline

bottle

diazepam

amp

gentamycin

amp

hydralazine

amp

methyldopa

tablet

metronidazole suspension

bottle

neostigmine

amp

pancurarium

amp

pethidine

amp

phenobarbitone

tablet

prochlorperazine

amp

sterile water

vial

suxamethonium

amp

thiopentone sodium

amp

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FOR ALL FACILITIES: 25. Inventory of Basic Medical Supplies

Recorded Quantity

Physical

Count

Last Purchase

Price

antenatal record

glass slide

glass tube, blood, red top

glass tube, capillary

lancet

reagent for blood typing

syringe and needle

urine dipsticks (bottle of 100)

VDRL kit

FOR ALL FACILITIES PERFORMING NORMAL DELIVERIES: 26. Inventory of Additional Medical Supplies

Recorded Quantity

Physical

Count

Last Purchase

Price

branula

cord clamps

gauze, absorbent

gloves, non-sterile (pair)

gloves, sterile (pair)

IV set

jik 1 L

sutures, chromic or plain catgut

FOR HOSPITALS OFFERING REFERRAL CARE OR OBSTETRIC SURGERY: 27. Inventory of Surgical Supplies

Recorded Quantity

Physical

Count

Last Purchase

Price

adhesive tape, roll

elastoplast, roll

endotracheal tube sz 7.5

jug hibitens w/ water, 10 L

KY jelly, tube

paper caps

paper masks

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FOR HOSPITALS OFFERING REFERRAL CARE OR OBSTETRIC SURGERY: 27. Inventory of Surgical Supplies

Recorded Quantity

Physical

Count

Last Purchase

Price

partogram plastic bags, leakproof lg

scalpel blades sz 23

spirits 5cc

suction catheter sz 10

sutures, chromic catgut sz 1 or 2

swabs, abdominal lg (1/10 roll)

swabs, small ratex

syringe and needle, 20cc

syringe and needle, 2cc

syringe and needle, 5cc

STOCK OUTS OF TRACER DRUGS

If pharmacy stock records are routinely kept, record the number of days for which the following tracer drugs were out of stock during the previous six months. For each date on which stocks were drawn down to zero, count the number of days in each month until stocks were resupplied and write that number in the appropriate column. If there were no recorded stockouts in a month, enter 0. If no stock records were kept for a given item, leave it blank.

Month

28. Stock Outs of Tracer Drugs

4/97

5/97

6/97

7/97

8/97

9/97 amoxycillin

cap

benzathine penicillin

vial

cotrimoxazole

tablet

dextrose 5%

bottle

doxycycline

cap

ergometrine

amp

ferrous sulphate

tablet

lidocaine

ml

metronidazole

tablet

normal saline

bottle

oxytocin

amp

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DATA COLLECTOR OBSERVATIONS Notes about record keeping at the hospital: Other observations:

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REPRODUCTIVE HEALTH COMMODITIES STUDY

HEALTH CARE PROVIDER QUESTIONNAIRE

District:

Health Facility:

Facility Type: (PH=provincial hospital; DH=district

hospital; OH=Other hospital, MH=maternity or nursing home; HC=health center; DI=dispensary)

Facility Administration (G=government; M=mission,

N=Other NGO, P=owned by company or private individual)

Date:

Data collector:

Find out from the medical officer in charge the names of all staff currently present at this health facility who are routinely involved in prenatal care, delivery, treatment of post-natal complications, or treatment of STDs. From this list, randomly select the following clinicians to be interviewed:

Type Number OB/Gyn or other physician (if present) 1 clinical officer (if present) 1 nurse-midwife, nurse, or midwife 2

Locate the clinician and conduct the interview in a private location.

RESPONDENT BACKGROUND

After introducing the purpose of the study to the respondent, confirm that he/she is currently involved in treating women during pregnancy, delivery, or with STDs. Explain that you would like to ask some general questions about his/her background, training, and current duties.

29. Respondent gender

Check one

9 1 Male

9 2 Female

30. What is your highest level of qualification?

Check one category :

OB/Gyn Specialist

9 1.

GP or other medical specialty

9 2.

Clinical Officer

9 3.

Nurse WITH midwifery training

9 4.

Nurse WITHOUT midwifery training

9 5.

Midwife

9 6. 31. When did you graduate from your highest qualification?

Enter year graduated from highest training

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SERVICE PROVISION AND PRACTICE

32. Do you currently provide the following services?

Read and ask about each service separately

check box :

Antenatal care

9 1 Yes

9 0 No

Treatment of STDs

9 1 Yes

9 0 No

Normal delivery

9 1 Yes

9 0 No

Breech delivery

9 1 Yes

9 0 No

Caesarian section

9 1 Yes

9 0 No

Management of abortion complications/incomplete delivery

9 1 Yes

9 0 No

33. When was the last time you saw a woman for her first antenatal visit ?

Check one category :

Within the last week

9 1.

Within the last six months

9 2.

More than six months ago

9 3. skip to Q. 7

Never

9 4. skip to Q. 7

34. What medicines (including immunizations) or tests did you order or give to her?

Elicit spontaneous response; DO NOT READ OUT LIST. Probe for multiple responses by asking AAnything else?@

Medicine / Immunization

check : if mentioned

Test

check : if mentioned

chloroquine

9

blood grouping

9

ferrous sulfate

9

hemoglobin

9

folic acid

9

malaria smear

9

quinine

9

stool for ova and parasites

9

tetanus toxoid

9

urine analysis for glucose & protein

9

other (specify):

9

other (specify):

9

9

9

9

9

9

9

35. When was the last time you provided care to a woman with moderate

preeclampsia?

Check one category :

Within the last week

9 1.

Within the last six months

9 2.

More than six months ago

9 3. skip to Q. 9

Never

9 4. skip to Q. 9

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36. What medicines or tests did you order or give to her?

Elicit spontaneous response; DO NOT READ OUT LIST. Probe for multiple responses by asking AAnything else?@

Medicine

check : if mentioned

Test

check : if mentioned

diazepam

9

urine for protein

9

hydralazine

9

other (specify):

9

methyldopa

9

9

paracetamol

9

9

phenobarbitone

9

9

propranolol

9

9

other (specify):

9

9

9

9

9

9

37. When was the last time you cared for a women whose labor was not progressing

but who did NOT require a Caesarian section?

Check one category :

Within the last week

9 1.

Within the last six months

9 2.

More than six months ago

9 3. skip to Q. 13

Never

9 4. skip to Q. 13

38. What medicines or tests did you order or give to her before or during her delivery?

Elicit spontaneous response; DO NOT READ OUT LIST. Probe for multiple responses by asking AAnything else?@

Medicine

check : if mentioned

Test

check : if mentioned

dextrose 5%

9

other (specify):

9

diazepam

9

9

ergometrine

9

9

oxytocin

9

9

paracetamol

9

9

other (specify):

9

9

9

9

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39. When was the last time that you attended a normal delivery?

Check one category :

Within the last week

9 1.

Within the last six months

9 2.

More than six months ago

9 3. skip to Q. 11

Never

9 4. skip to Q. 11

40. What medicines or tests did you order or give to her?

Elicit spontaneous response; DO NOT READ OUT LIST. Probe for multiple responses by asking AAnything else?@

Medicine

check : if mentioned

Test

check : if mentioned

diazepam

9

other (specify):

9

ergometrine

9

9

paracetamol

9

9

vitamin K

9

9

other (specify):

9

9

9

9

41. When was the last time you treated a woman who was hemorrhaging before,

during, or after childbirth?

Check one category :

Within the last week

9 1.

Within the last six months

9 2.

More than six months ago

9 3. skip to Q. 17

Never

9 4. skip to Q. 17

42. What medicines (including blood and IV fluids) or tests did you order or give to her?

Elicit spontaneous response; DO NOT READ OUT LIST. Probe for multiple responses by asking AAnything else?@

Name of Medicine / Blood IV fluid

check : if mentioned

Test

check : if mentioned

ergometrine

9

other (specify):

9

oxytocin

9

9

blood transfusion

9

9

IV fluid (specify):

9

9

other (specify):

9

9

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9 9

9

9

43. When was the last time you performed a Caesarian section?

Check one category :

Within the last week

9 1.

Within the last six months

9 2.

More than six months ago

9 3. skip to Q. 15

Never

9 4. skip to Q. 15

44. What medicines (including IV fluids, anesthesia, and analgesics) or tests did you order or give during the

Caesarian section? Elicit spontaneous response; DO NOT READ OUT LIST. Probe for multiple responses by asking AAnything else?@

Medicine

check : if mentioned

Test

check : if mentioned

atropine

9

other (specify):

9

dextrose 5%

9

9

neostigmine

9

9

normal saline

9

9

oxytocin

9

9

paracetamol

9

9

pethidine

9

9

prochlorperazine

9

9

sterile water

9

9

suxamethonium

9

9

thiopentone sodium

9

9

other (specify):

9

9

9

9

9

9

45. When was the last time you treated a women with postpartum sepsis?

Check one category :

Within the last week

9 1.

Within the last six months

9 2.

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More than six months ago 9 3. skip to Q. 19

Never

9 4. skip to Q. 19

46. What medicines (including IV fluids) or tests did you order or give to her?

Elicit spontaneous response; DO NOT READ OUT LIST. Probe for multiple responses by asking AAnything else?@

Medicine

check : if mentioned

Test

check : if mentioned

amoxycillin

9

other (specify):

9

ampicillin

9

9

dextrose 5%

9

9

gentamycin

9

9

metronidazole

9

9

paracetamol

9

9

other (specify):

9

9

9

9

47. When was the last time you treated a woman with urinary tract infection?

Check one category :

Within the last week

9 1.

Within the last six months

9 2.

More than six months ago

9 3. skip to Q. 21

Never

9 4. skip to Q. 21

48. What medicines or tests did you order or give to her?

Elicit spontaneous response; DO NOT READ OUT LIST. Probe for multiple responses by asking AAnything else?@

Medicine

check : if mentioned

Test

check : if mentioned

ampicillin

9

other (specify):

9

amoxycillin

9

9

cotrimoxazole

9

9

erythromycin

9

9

metronidazole

9

9

nitrofurantoin

9

9

other (specify):

9

9

9

9

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49. When was the last time you treated a woman with genital ulcers?

Check one category :

Within the last week

9 1.

Within the last six months

9 2.

More than six months ago

9 3. skip to Q. 23

Never

9 4. skip to Q. 23

50. What medicines or tests did you order or give to her?

Elicit spontaneous response; DO NOT READ OUT LIST. Probe for multiple responses by asking AAnything else?@

Medicine

check : if mentioned

Test

check : if mentioned

amoxycillin

9

9

benzathine penicillin

9

other (specify):

9

ciprofloxacin

9

9

doxycycline

9

9

erythromycin

9

9

norfloxacin

9

9

other (specify):

9

9

9

9

51. When was the last time you treated a woman with a vaginal discharge?

Check one category :

Within the last week

9 1.

Within the last six months

9 2.

More than six months ago

9 3. skip to Q. 25

Never

9 4. skip to Q. 25

52. What medicines or tests did you order or give to her?

Elicit spontaneous response; DO NOT READ OUT LIST. Probe for multiple responses by asking AAnything else?@

Medicine

check : if mentioned

Test

check : if mentioned

amoxycillin

9

other (specify):

9

augmentin

9

9

doxycycline

9

9

erythromycin

9

9

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norfloxacin

9

9

probenecid

9

9

other (specify):

9

9

53. When was the last time that you treated a woman with vaginal discharge and lower

abdominal pain?

Check one category :

Within the last week

9 1.

Within the last six months

9 2.

More than six months ago

9 3. skip to Q. 27

Never

9 4. skip to Q. 27

54. What medicines and/or tests did you order or give to her?

Elicit spontaneous response; DO NOT READ OUT LIST. Probe for multiple responses by asking AAnything else?@

Medicine

check : if mentioned

Test

check : if mentioned

amoxycillin

9

other (specify):

9

doxycycline

9

9

erythromycin

9

9

metronidazole

9

9

norfloxacine

9

9

other (specify):

9

9

This is the end of the interview. Thank the participant for his/her time.

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EPRODUCTIVE HEALTH COMMODITIES STUDY

MOTHERS INTERVIEW FORM

District:

Health Facility:

Date of

Interview:

Data Collector:

This form should be used for interviewing (1) women who just gave birth and are still in their post-natal stay, or (2) pregnant mothers attending MCH clinic. After introducing yourself and the survey, explain that you would like to ask about her experience during pregnancy (and birth, if she has already delivered.)

a. Antenatal clinic attender

9

55. Type of Respondent (check one):

b. Post-natal mother

9

ANTENATAL CARE

56. How many months pregnant were you when you first visited a health

facility for antenatal care during this pregnancy? Enter number of months; If no antenatal visits, enter 0

If no ANC visit, skip to Q. 6 57. What kind of health facility did you attend for your first antenatal visit?

Read list and check one

check one type :

a. government hospital

9 1.

b. mission hospital

9 2.

c. government health center

9 3.

d. government dispensary

9 4.

f. other (specify):

9 5. 58. Did they do any of the following during your first antenatal visit?

Read each item and record response; leave item blank if mother does not know

check box :

a. take a blood sample from you or prick your thumb for tests?

9 1 Yes

9 0 No

b. take urine from you for tests?

9 1 Yes

9 0 No

c. take stool from you for tests?

9 1 Yes

9 0 No 59. Did you receive any drugs or injections during your first antenatal visit?

9 1 Yes

9 0 No

skip to Q. 6 60. Which drugs were they?

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Elicit spontaneous response; DO NOT READ LIST; probe by asking AAnything else?@ check boxes:

drug for anemia (iron folate, ferrous sulfate, folic acid)

9

vitamin

9

tetanus immunization

9

malaria medication

9

others (specify):

9

61. Overall, please tell me all the drugs that you are taking (or have taken) during your

pregnancy, including those suggested by health workers and those you got for yourself. Elicit spontaneous response; DO NOT READ LIST; probe by asking AAnything else?@

check box(es) :

drug for anemia (iron folate, ferrous sulfate, folic acid)

9

vitamin

9

tetanus immunization

9

malaria medication

9

others (specify):

9

If the respondent is a mother attending an antenatal clinic, skip to the end of the interview.

COMMODITIES AND COST FOR DELIVERY

If yes, enter no. and cost 62. Were you asked to bring any of the following drugs

or supplies to this facility for your delivery? Read list, check box, and enter number and cost of each item

check box :

Number

Cost

gloves

9 1 Yes

9 0 No

sutures

9 1 Yes

9 0 No

drugs (specify):

9 1 Yes

9 0 No

mackintosh

9 1 Yes

9 0 No

other (specify):

9 1 Yes

9 0 No

63. In total, how much did you spend to buy items that you needed for your delivery?

Enter the amount; If not known or if no items were purchased, enter 0

64. Finally, I would like to know a few things about your labor and delivery.

check box :

a. Did you have surgery for your delivery?

9 1 Yes

9 0 No

b. Did you receive any IV drugs while you were in the labor room?

9 1 Yes

9 0 No

c. Did you receive a blood transfusion?

9 1 Yes

9 0 No

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This is the end of the interview. Thank the respondent for her time and ask if she has any questions.

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MATERNAL HISTORY FORM

Patient Number:

Age:

Date

Reason for Visit

Drug Name/Strength or Lab Test Dose/Quantity Code

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Date

Reason for Visit

Drug Name/Strength or Lab Test Dose/Quantity Code

Comments:

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PATIENT CONTACT FORM

District:

Health Facility:

Data Collector:

Date:

Type*

Patient ID

Visit Date Age Prescriber*

Describe Conditions/Health Problems Code

Drug Name/Strength or Lab Test Dose/Quantity Code

Drugs or Lab Tests

Comments (e.g., outcomes or complications):

* Type: 1=delivery, 2=Cesarian section, 3=hemorrhage, 4=sepsis, 5=STI, 6=UTI, 7=current ANC

Type* Patient ID Visit Date Age Prescriber

Describe Conditions/Health Problems Code

Drug Name/Strength or Lab Test Dose/Quantity Code

Drugs or Lab Tests

Comments (e.g., outcomes or complications):

Prescriber: 1=doctor, 2=clinical officer, 3=nurse, 4=midwife, 5=ot

87