STANFORD-UON-NOKIA RESEARCH CENTRE

STANFORD-UON-NOKIA RESEARCH CENTRE

STANFORD-UON-NOKIA RESEARCH CENTRE

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RESEARCH AREA: ACCESS TO MEDICAL CARE
TARGET: LOW-INCOME COMMUNITIES
GROUP IV: HOSPITAL MANAGEMENT
FIELDWORK REPORT

INTRODUCTION
The aim of this research was to analyze the current management situation of medical centres in low income community (LIC) areas. Fieldwork was carried out in various sites to assess different medical facilities on how they are run, services they provide to LICs, challenges they are facing and to seek recommendations on how to solve these problems.
Background and Overview
Kenya’s Health-care System and Structures (Health Delivery System)
The National Health Sector Strategic Plan II (NHSSP II) 2005-2010, specifies six levels of Kenya’s Health Delivery System structure. Each level has both service delivery and management functions to ensure efficient and effective delivery of health services. The organizational structure of the health system is as illustrated in the hierarchical diagram below:

i.    Level 1
This is the community level which forms the foundation of service delivery. Activities here are focused on ensuring that individuals, households, families and villages carry out appropriate healthy behaviours, and recognize signs and symptoms of conditions that need to be managed at other levels of the system.

ii.    Levels 2-3
This level consists of dispensaries, health centres, maternity and nursing homes and forms the interface between the community and the Physical Health System. It involves community health workers in the prevention and curing of common diseases such as malaria, cholera, diarrhoea, simple skin diseases and other illness;

Figure 4.1: Kenya’s health-care system structure
Source: NHSSP II, 2005-2010
iii.    Levels 4-6
Level 4 consists of primary hospitals. They provide the following services:
•    Clinical supportive supervision to lower level facilities
•    Health activities e.g. Referral level outpatient care, Inpatient services, Emergency obstetric care, Oral health services, Surgery on inpatient basis, Client health education, More specialized laboratory tests and Radiology services
•    Providing logistical support to the lower facilities in the catchment area and coordinating information flow from facilities in the area.
Level 5 consists of Secondary Hospitals. They aim at ensuring a wide scope of potential health needs of the communities at a point where they have access. Training facilities are also offered for personnel at the primary hospitals e.g. nursing staff and clinical officers. Management related activities that support level 5 are coordinated through the office of the Provincial Medical Officer of Health.
Level 6 consists of tertiary Hospitals. It contains all the remaining specialized services that are most efficiently provided at a national level. It includes training facilities for specialized health workers that function at the secondary and tertiary care, up to degree and postgraduate levels.

Informant Profiles
a.    Hospital Manager/Administrator
b.    Public Health Officer

a.    Hospital Manager/Administrator
Hospital managers/administrators play a very vital role in the smooth running of a hospital, clinic or any other medical facility. They perform supervisory roles in order to provide a safe environment for both employees and patients. They are expected to co-ordinate and supervise the entire medical facility. However, medical administrators in smaller clinics perform more detailed duties than those at large hospitals. Clinic managers handle financial operations and all patient and personnel issues but in large hospitals there are other people who are assigned that duty.
Medical administrators in Kenya do not necessarily hold a degree in the medical field but have received training in health administration. Medical administrators should be able to work well with many types of people so that the people they serve feel free to tell them of their problems and together look for ways of ensuring that their needs are well attended to.


Figure 4.2: Skills needed by health managers in Kenya
Source: Report on Management and Leadership Gaps for Kenya Health Managers; Ministry of Public Health and Sanitation, Ministry of Medical Services. Nov 2007-August 2008

Hospital administrators in Kenya receive training from local institutions such as universities or other tertiary institutions that offer programs in the medical field, health administration or management in general.
b.    Public Health Officer (P.H.O.)
A public health officer is responsible for ensuring that the organization they are working for has an occupational health and management system in place.  They monitor the occupational health and management systems in place on a daily basis to ensure that they are working properly.

The public health officer also assists in promoting and protecting the health and well-being of the population by planning, implementing, monitoring and evaluating strategies, programmes and initiatives for promoting the health and well-being of the population. They improve the quality of health and healthcare services and interventions through audit and evaluation.

They also act as a source of advice for colleagues and cross-professional working groups on appropriate research methodologies, including monitoring and evaluation techniques.
Public health officers provide and contribute to public health research and intelligence by:
i.    Information retrieval from routine data sources and the literature
ii.    Simplifying complex research outcomes into information and knowledge that can be used to improve health and wellbeing;
iii.    Analyzing data, drawing appropriate conclusions, and making recommendations.

In Kenya, most public health officers receive their training from local institutions of higher learning such as local universities and medical training colleges. A four-year bachelor’s degree in Public Health or Public Health Administration is available in the local universities such as Moi University, Eldoret. Post-graduate degree programmes in the same are also available such as a Masters in Public Health Administration offered by the University of Nairobi and Moi University.
Public Health Officers are mostly hired by the government to work at national, constituency and district level so as to serve the health needs of the community more effectively. 


REFERENCES
•    Kenya’s Health Policy Framework 1994-2010. Ministry of Health. November 1994, 1997
•    Ministry of Medical Services, Strategic Plan 2008-2012. Ministry of Medical Services. July 2008
•    Ministry of Public Health and Sanitation, Strategic Plan 2008-2012. Ministry of Public Health and Sanitation. December 2008
•    Report on Management and Leadership Development Gaps for Kenya Health Managers, Reversing Trends to Enable Managers to Lead. Ministry of Public Health and Sanitation, Ministry of Medical Services. November 2007-August 2008.
•    Ministry of Health June 2006, Taking the Kenya Essential Package for Health to the Community: A Strategy for the Delivery of Level One Services. Ministry of Health.
•    [Internet source]. Cfk.unc.edu/Tabitha-clinic.


SITE PROFILES
1.    Kariokior Health Office
The Kariokor Health Office is a government-owned facility administered through the City Council of Nairobi (CCN). It is located in Starehe Constituency about 10 minutes away from the Nairobi city centre next to the Kamukunji District Officer’s office.
There is also a clinic within the premises of the health office that provides child immunization services to children under the age of 5 years and a Voluntary Counseling and Testing (VCT) services.
Kamukunji District has a number of health facilities, some of which include:
•    Eastleigh Maternity
•    Eastleigh Health Centre
•    Muthurwa Health Centre
•    Biafra Clinic
•    Jericho Clinic
•    Pumwani Maternity Hospital
•    Majengo Health Centre
•    Bahati Maternity
•    Bahati Clinic
•    Shauri Moyo Clinic

2.    St. Mary’s Mission Hospital, Langata
St. Mary’s Mission Hospital was founded in the year 2000 by the Catholic Church Mission to serve low-income communities in Langata, mostly the vast Kibera with an estimated population of more than one million residents.
Its catchment area has expanded over the years to include Kinoo, Umoja, Kitengela and even Coast province. The hospital also receives patients from as far as Ethiopia, Uganda, Tanzania and Somalia.
The objective of the hospital is to provide affordable health-care to low-income communities in a Christian environment. Not only is medical care provided but also spiritual nourishment and counseling are highly regarded in the hospital.
3.    Tabitha Clinic, Kibera
Tabitha Clinic is a health facility located in the heart of Nairobi’s largest slum, Kibera. It mainly serves Kibera residents by providing affordable medical services to the population.
Tabitha Clinic is a 3-storey, 13-room facility that provides basic laboratory, pharmaceutical, children’s services and youth-friendly services such as VCT services.
It is owned by an NGO called Carolina for Kibera (CFK). The clinic partners with the Kenya Medical Research Institute (KEMRI), the U.S. Centers for Disease Control and Prevention (CDC) and the University of North Carolina.






















RESEARCH FINDINGS
INFORMANTS

Site    Respondents
St. Mary’s Mission Hospital     i.    Doctor in-charge
ii.    Assistant Matron Nurse, Female Surgical Ward
iii.    Medical Records Keeper
Tabitha Clinic, Kibera    i.    Clinic Manager
Kariokor Health Office    i.    District Public Health Officer


QUESTIONS
A. HOSPITAL MANAGEMENT
1.    How long have you worked in this area?
SITE    RESPONDENT     RESPONSE
St. Mary’s Mission Hospital, Langata    Doctor in-charge    5 years
    Assistant Matron Nurse, Female Surgical Ward    7 years

    Medical Records Keeper    8 years
Tabitha Clinic, Kibera    Clinic Manager    4 years

2.    Who owns the facility e.g. private, government-owned, church organizations, NGOs etc?
SITE    RESPONSE
St. Mary’s Mission Hospital, Langata    It is a Catholic Church Mission Hospital founded in the year 2000 to serve low-income communities in Langata, mostly the vast Kibera population. Its catchment area has expanded over the years to include Kinoo, Umoja, Kitengela and even Coast province. The hospital also receives patients from as far as Ethiopia, Uganda, Tanzania and Somalia.
The objective of the hospital is to provide affordable health-care to low-income communities in a Christian environment. Not only is medical care provided but also spiritual and counseling care highly regarded in the hospital.
Tabitha Clinic, Kibera.    Owned by an NGO called Carolina for Kibera. It partners with the Kenya Medical Research Institute (KEMRI), the Centers for Disease Control and Prevention (CDC) and the University of North Carolina.




HUMAN RESOURCE
3.    How many health practitioners do you have working in your centre?
SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    Role    Number
Doctors    18
Clinical Officers    11
Nurses    65
Pharmacists and Pharmaceutical Technicians    8
Laboratory Technicians    9
Support Staff    46
Guards    9

Consultant    Number
Surgeons    3
Gynecologists    3
Radiologist    1
Pediatrician    1

Tabitha Clinic, Kibera.    Role    Number
Doctors    2
Patient Attendants    2
Nurses    8
Pharmacists    2


4.    On average, how many patients are attended to per day?

SITE    RESPONSE    OTHER ISSUES
St. Mary’s Mission Hospital, Langata.    800-1000 Per day    About 80%-90% of the patients served in a day are from low-income communities.
Tabitha Clinic, Kibera.    200-250 Per day    The highest number of patients that has ever been served by the clinic in on day is 298.

5.    Do you feel that the number of staff available is adequate in attending to patients?

SITE    RESPONDENT    RESPONSE
St. Mary’s Mission Hospital, Langata.    Doctor in-charge.    YES, apart from a few occasions when patient numbers are high
    Assistant Matron Nurse, Female Surgical Ward.
    Enough, but we have few medical specialists and work is overwhelming when patient numbers are higher than expected.
    Medical Records Keeper    No, there is a high workload.
Tabitha Clinic, Kibera.    Clinic Manager.    YES, but at times patients overwhelm staff. Few specialists to handle some diseases and medical cases


6.    How does the management check staff attendance?
SITE    RESPONSE    OTHER ISSUES
St. Mary’s Mission Hospital, Langata.    Staff attendance is checked by in-charges (staff that keeps track of the attendance levels of other staff in the hospital) using checklists.    Nurses who are supposed to be on off, especially after working night shifts, can still work extra hours during the day and are paid an hourly overtime allowance called ‘mradi’ or token. This helps the facility in handling the large number of patients without having to bring in other nurses from outside to fill the gaps left by those on leave.
Tabitha Clinic, Kibera.    N/A   








7.    What are the challenges faced by the medical staff while administering medical care to their patients?

SITE    RESPONDENT    RESPONSE
St. Mary’s Mission Hospital, Langata.    Doctor in-charge.    i.    Uncertainty of the number of patients per day.
ii.    Inadequate number of medical staff
iii.    Few medical equipment and limited variety in the existing ones.
    Assistant Matron Nurse, Female Surgical Ward.    i.    Limited staff housing within the hospital vicinity (90% housed by hospital). Some of the medical staff is forced to find alternative housing away from the hospital leading to commuting difficulties
ii.    Few medical specialists
Tabitha Clinic, Kibera.    Clinic Manager    i.    Most staff are not computer literate
ii.    Frequent system network failure and computer virus infections.
iii.    Patients at times overwhelm staff
iv.    Small facility and few specialists to handle some diseases
v.    Referrals are mostly to costly hospitals.





MANAGEMENT:

8.    Do you offer patient admittance (inpatient) facilities?

SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    YES, both inpatient and outpatient facilities
Tabitha Clinic, Kibera.    NO, it is purely an outpatient facility

9.    If yes, what is the bed capacity at your facility?

SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    The hospital has a bed capacity of approximately 400 beds. The beds are the spread out equally between the different wards.
Tabitha Clinic, Kibera.    N/A

10.     a) What kinds of wards does your facility have and what is the capacity of each ward?
b) Are there instances where you admit more patients than can be accommodated by the bed capacity? 

SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    i.    Men’s ward, divided into Medical and Surgical wards
ii.    Female ward, also divided into Medical and Surgical wards
iii.    Children’s ward
iv.    Maternity ward, consisting of Antenatal and Post-natal wards
Each ward has a capacity of 40 beds, although reserve beds are kept in case more patients need to be admitted than can be accommodated by the current bed capacity. In such cases, more beds are brought into the wards and the beds squeezed together to create room such that no patient sleeps under or shares a bed as seen in other hospitals.


11.    Is there a referral system in place? Under what circumstances are referrals done?

SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    The hospital carries out few referrals because it offers most of the services that patients need. The circumstances under which referrals to other hospitals are done include:
•    Patients who need kidney dialysis, heart surgery, ICU
•    Patients with physical disabilities
•    Patients who need psychiatric attention
The main hospital where patients are referred to is Kenyatta National Hospital, the largest referral hospital in the region.
Tabitha Clinic, Kibera.    Referrals are upon agreement with major Hospitals in cases of special attentions i.e. to Mbagathi District Hospital and KNH.


12.    Do you have facilities to cater for those with physical disabilities?

SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    The hospital offers physiotherapy for some patients but most cases are referred to other hospitals.
Tabitha Clinic, Kibera.    Most patients are referred to other with specialized facilities.

13.    What are some of the common diseases or outbreaks in the area and how does the medical facility deal with outbreaks if they occur?

SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    The most common diseases include: Malaria, typhoid, diarrhea, cholera, pneumonia, HIV/AIDS, swelling of the pelvis among the elderly, fibroids (requiring operation), appendicitis, cancer of the cervix, breast and esophagus
Common outbreaks include: Typhoid, diarrhea, cholera, pneumonia, measles, flu and meningitis.
Outbreaks are reported to the Langata Health Centre through which public health officers are notified so as to take further action.
Tabitha Clinic, Kibera.    Common diseases/illnesses in the area include: Eye infections, pneumonia, malaria, diarrheal diseases, Swine flu (H1N1), and cholera.
The most common outbreak is cholera and recently Swine flu.
During outbreaks, patients are treated; families and neighbouring communities are informed on how to avoid getting infected. Referral and follow-ups are done if necessary.
Kariokor Health Office    Common diseases and outbreaks: Diarrheal disease and cholera due to poor sanitation, high risk of water contamination, food prepared in unhygienic conditions in “vibandas” (common eating places).
Handling of outbreaks includes: Isolation of victims, getting contacts of their close relatives, establish outbreak source and address causative agent.

SITE    OTHER ISSUES
St. Mary’s Mission Hospital, Langata.    Some of the causes of these outbreaks, Typhoid and diarrhea, include:
i.    Poverty
ii.    Poor sanitation in Kibera e.g. latrines located by water sources leading to contamination
iii.    Overcrowded residences
 Ignorance in the community about proper hygiene, or the information passed on hygiene is non-penetrative
Tabitha Clinic, Kibera.    Two cases of cholera were recently handled in the clinic.
Normally, when one case of a common outbreak or disease is reported, the clinic has to prepare to handle an outbreak because diseases/outbreaks spread fast in Kibera.
Kariokor Health Office    There are few mortuary facilities serving the whole of Nairobi province, e.g. City Mortuary, which are distanced from Kamukunji district.

FINANCE:
14.    Do you offer any free medical services? E.g. free eye tests, check-ups etc.

SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    The hospital does not offer free services within the hospital but has community outreach programmes where it offers free eye clinics, dental clinics and general medical check-ups.
Tabitha Clinic, Kibera.    YES, patients in the surveillance programme in the villages receive free services e.g. diarrhea, malaria. HIV patients also receive free medical care and specialized tests.


15.    How affordable are the medical services available to the community?

SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    Consultation fee of KSh.100 (U.S. $.1.3) per visit. KSh.4000 - 5000 for surgery and maternal delivery (caesarian delivery).
Tabitha Clinic, Kibera.    First time patients pay KSh.100 for the card. A consultation fee of KSh.50 is charged for each subsequent visit. Otherwise, 90% of medical services are free.
Kariokor Health Office    In most of the hospitals and clinics in the area, consultation fee is KSh.20 for adults and free for children below 5 years. Patients spend about KSh.100 in purchasing medication from the government pharmacies.


16.    What measures do you take when patients cannot afford to pay their medical bills?

SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    Patients who cannot afford to pay for medical services rendered end up with a bad debt. To handle such cases, a patient’s next of kin fills-in a liability form as an assurance of payment.
Tabitha Clinic, Kibera.    The clinic has an emergency kitty that pools funds from well-wishers that is used when cannot afford to pay their bills.
SITE    USER STORIES
Tabitha Clinic, Kibera.    There was an instance when a patient could not clear their medical bill and therefore the hospital took out KSh.35, 000 from the medical emergency kitty to assist the patient pay his bill.

17.    Does the medical facility partner with insurance firms that provide medical cover for patient in LICs?
SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    The hospital partners with micro-insurance firms especially Jamii Bora. Patients and donors open an account with Jamii Bora in which they deposit money. The hospital then bills the insurance firm at the end of the month. Insurance firms who are in profit business are discouraged.
Tabitha Clinic, Kibera.    Most insurance schemes are too expensive to the residents. However there are some small local insurance schemes where residents pay as little as KSh.5 a month.

18.    What financial measures do you think should be taken to improve access to healthcare for low-income earners?
SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    i.    Seeking funds from well-wishers (individuals) so as to provide subsidized medical services.
ii.    The government and NGOs also assist in supplying HIV/AIDS medication.
Tabitha Clinic, Kibera.    Encouraging well-wishers to donate funds to the medical kitty to assist patients who cannot afford medical services.


RECORDS SITUATION:

19.    How do you manage patient records at the facility?
SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    More than 90% of the records kept are manual. Filing is done numerically by order of the patient number.
There are different types of records kept in the hospital, some of which include: Inpatient records, admission records, occupation records, investigation records (lab tests), referral records and reports.
On arrival, a patient is first issued with a card at the gate. The card has a patient number which will be used to reference the patient at all times.
During registration, the patient’s personal details are recorded e.g. name, age, place of residence etc.
Patients are then classified according to their purpose of visit e.g. to visit surgeon, gynecologist, check-up etc.
Medical records are supposed to be disposed of after 15 years. Therefore, the hospital has not carried out any disposal yet.
Tabitha Clinic, Kibera.    This is a completely paperless clinic. It uses a computerized Patient-Care System developed by a private consultant.
Each patient must have a card which is then scanned using a barcode reader to add him/her to the queue.
The system handles patient queues, diagnosis by nurses and doctors, laboratory tests monitoring and pharmaceutical dispensing.
Paper documents are kept for HIV positive patients for research purposes (research patients).
Every person using a laptop has to sign in for the laptop and sign out at the end of the day.

20.    What are the challenges faced in the current medical record management system?
SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    i.    Voluminous paperwork due to many patients
ii.    Insufficient space for keeping documents or filing records
iii.    Retrieval of records is tedious
Tabitha Clinic, Kibera.    i.    Software and hardware challenges, especially viruses. The clinic carries out virus clean-ups every Saturday.
ii.    Sometimes the wired or wireless network is down and may require specialists to troubleshoot if it is a complex problem.

21.    In your opinion what do you think should be done to improve on the current medical record management system?

SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    i.    Create bigger space for storage of records
ii.    More personnel to manage records
iii.    Introduction of a computerized system to minimize paperwork
Tabitha Clinic, Kibera.    Training more medical personnel on the use of the existing Patient-Care System.


SITE    USER STORIES
Tabitha Clinic, Kibera.    Some patients show up at the clinic with cards that do not belong to them and have to be sent back home after the card has been scanned.



PROCUREMENT:

22.    Where do you get medication and equipment from?

SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    Medicine is supplied by the Mission for Essential Drugs and Supplies (MEDS), a Christian not-for-profit organization based in Nairobi.
Medical equipment is bought from suppliers such as Johnson and Johnson. It is also sometimes imported from the USA and paid through donations. Some of the equipment available the facility include: x-ray machine, laboratory equipment etc.
Tabitha Clinic, Kibera.    Medicine is supplied by Mission for Essential Drugs and Supplies (MEDS) and church organizations on monthly orders.
Equipment is supplied by donor organizations. The hospital has the latest equipment e.g. pulse oximeter

23.    How often do you replace or perform maintenance on the equipment?

SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    Maintenance is done by the maintenance department and in extreme cases, by the equipment supplier.
Tabitha Clinic, Kibera.    Data specialists handle troubleshooting of the wired and wireless computer networks. Some employees have also been trained in handling basic computer troubleshooting.

SITE    OTHER ISSSUES
Tabitha Clinic, Kibera.    The clinic is still setting up medical equipment e.g. the first x-ray machine is currently being installed and will hopefully be ready by the end of March, 2010.
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B. PUBLIC HEALTH OFFICER
1.    Do you have access to clean water?  From what source?
SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    Yes, the hospital has three boreholes which provide all the water used in the facility.
Tabitha Clinic, Kibera.    Main Water source is Nairobi Water Company (direct source line to avoid tapping and contamination)
Alternative water sources include underground rain-water collection tanks with an internal mini-purifying system. The clinic also has solar heaters to heat the water.
Kariokor Health Office    Main source of water is the Nairobi Water Company. Alternate sources: Borehole(only in Pumwani Maternity Hospital)

2.    How do you manage power blackouts? What alternative power sources are available?

SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    Power is provided by the Kenya Power and Lighting Company (KPLC). The hospital also has an automatic generator which kicks- in during power outages.
Tabitha Clinic, Kibera.    Main power source is Kenya Power and Lighting Company. The clinic has its own transformer that is stepped down to supply the required voltage.
Kariokor Health Office    The only power source is the Kenya power and Lighting Company (KPLC).

3.    Are emergency medical services, such as ambulances, accessible within the slum areas?
SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    The hospital does not have an ambulance and therefore relies on other emergency medical services such as St. John’s Ambulance and Nairobi Hospital ambulances.
Tabitha Clinic, Kibera.    No formal Ambulance System. Carolina for Kibera has a truck that the use in case of emergencies.
Private taxis that have an arrangement with the clinic are mostly relied on for transport services.
Kariokor Health Office    The whole district is served by three ambulances but at the time of the research, one was broken down.

4.    What are the most reliable means of transport to the medical facilities in the area?

SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    The main mode of transport used by patients to get to the hospital is matatus (public service vehicles), which cost between KSh.10-100 within Nairobi.
Tabitha Clinic, Kibera.    Most patients walk to the clinic because it is located within Kibera. Taxis and matatus are also used.
Kariokor Health Office    The location of most health facilities is strategic and reachable from residential areas, mostly by foot or matatus.

5.    What are the most common problems faced by residents who try to access medical care in the available health centres? What are the reasons for these access problems?
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SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    i.    Some patients have to travel over long distances e.g. from Coast province all the way to Langata, Nairobi at night, to get to St. Mary’s because of its affordability.
ii.    Long queues at the hospital due to many patients in which case patients have to wait for long hours before they can be attended to.
Tabitha Clinic, Kibera.    i.    Language barrier and illiteracy in the community becomes a major hindrance during medical consultation. Sometimes the clinic has to use nurses or community health workers who can speak local dialects to communicate with the patients.
ii.    Patients expect services which cannot be offered by the clinic hence when referred to other medical facilities, they end up not affording the costs.
iii.    There are thousands of clinics in Kibera but only about 5 of them provide quality medical care, including Tabitha clinic.
iv.    The clinic is too far for some residents
v.    Most clinics in Kibera are closed over the weekend hence residents have to seek medical assistance in alternative places, probably more expensive or rely on cheap unqualified medical practitioners.
Kariokor Health Office    N/A
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6.    Are there any cultural practices in this area preventing people from accessing medical care?
If yes:
•    What are some of the practices?
•     How do they affect access to medical care?
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SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    Yes, cultural and religious beliefs are sometimes a problem. This is mostly at village level. Some patients reject blood transfusion even when they have anaemia. However, this being a Christian hospital, we still get Muslim patients.
Tabitha Clinic, Kibera.    Yes, there are cultural practices in the area that hinder access to medical care .e.g. Misinterpretation of the Carolina for Kibera and KEMRI logos by the residents makes them not to come to the clinic or avoid such things as blood sampling.
Kariokor Health Office    N/A
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7.    In your opinion, how can access to health information by medical personnel be improved?
SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    Training medical staff on basic computer skills
Tabitha Clinic, Kibera.    Working more with medical training organizations e.g. Mild May, during CME sessions

8.    How do you think access to health information by residents of this area can be improved?
SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    Working more with community health workers and NGOs to convey health information to the community
Tabitha Clinic, Kibera.    i.    Organizing more ‘barazaas’ (informal meetings)through local leaders e.g. chiefs
ii.    Providing health information material to patients at the waiting area in the clinic e.g. pamphlets, fliers, TV set running information on health etc.
iii.    Use of medical staff to impart health knowledge to residents in local dialects.
iv.    Organizing more community ‘barazaas’ (informal meetings) to sensitize the residents on health related matters.
v.    Increasing community outreach programmes
Kariokor Health Office    Organizing more ‘barazaas’ through local leaders e.g. chiefs to convey health information to the residents.
9.    Do you think people in this area adhere to their medical appointments? If not, why don’t they do so?
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SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    An average of 90%-98% of patients who visit the hospital make return visits e.g. surgical patients, outpatient check-ups done at the first phase (after 2 weeks) and can then be referred to other clinics of hospitals for subsequent check-ups.
Medical records are used to ensure that appointments are adhered to thus allowing follow-ups. Referral letters are used when a patient is referred to another medical facility.
Tabitha Clinic, Kibera.    Yes, most patients make return visits. Peer educators do follow-ups and sometimes nurses or clinical officers.
Appointment cards and diaries are used to manage appointments for HIV patients.
However, there are some patients that do not make return visits because they feel much better after taking medication and end up not even finishing dosages due to poor sensitization.
Kariokor Health Office    Yes, most patients adhere to appointments.
10.    What measures would you recommend to be put in place in order to ensure that Medical care offered at the Health Facilities is easily accessible to those living in low-income communities?
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SITE    RESPONSE
St. Mary’s Mission Hospital, Langata.    i.    Liaise more with NGOs e.g. health workers
ii.    Get more financial aid especially from well-wishers
iii.    Educate the public more on proper hygiene methods and avoiding chronic illnesses
iv.    Government legislation is required to provide quality medical care but still low-cost
Tabitha Clinic, Kibera.    i.    Working more with well-wishers to contribute to the patients’ medical kitty
ii.    Sensitizing patients on proper hygiene and providing health information through community health workers
iii.    More sensitization and mobility needed about insurance schemes residents in LICs
Kariokor Health Office    i.    Increase PHO to population ratio, currently standing at 1:400,000.
ii.    Facilitate transportation of PHOs to clinics and residential for proper supervision.

CHALLENGES FACED IN PROVIDING AND ACCESSING MEDICAL CARE IN LICS
•    The main challenge faced in access to health care in LICs is mainly inadequate money to cater for all their medical needs. Most people are too poor to afford good quality medical care. Due to this they end up going to quacks who offer substantial services and they only go to proper health facilities when their condition has seriously deteriorated and by then it is probably too late.
•    Another issue is that these slum dwellers can be ignorant since they do not have access to proper health information. In some of the areas we visited we noticed that information dissemination is not very efficient. Some residents opt to self-medicate and yet they may be ‘treating’ a condition that they do not actually have. In some cases, one may take their neighbour’s left-over medicine simply because the symptoms they have are similar to those that the neighbour was treated for.
•    Health facilities are faced with a big problem of having outstanding medical bills since the patient has been treated but cannot be able to clear the bill. In such a situation the hospital has to appeal to well-wishers to clear the outstanding bills.
•    Another issue is that some people may have certain cultural and religious beliefs that hinder them from accessing medical care. In one of the sites we visited i.e. Tabitha Clinic, the Carolina for Kibera logo was misinterpreted by the residents to mean that the management of the hospital and its entire staff worshipped the sun god and this stopped them from going to the facility for a while.
•    Some of the health facilities are not easily accessible or too far from the residents. The infrastructure in place e.g. roads, is very poor. Patients in some cases have to travel over long distances and pay a lot of money to get to affordable medical facilities e.g. St. Mary’s Hospital, Langata. 
•    Poor sanitation in most urban slum dwellings e.g. poor drainage systems, improper garbage disposal, therefore creating a health hazard to residents.
•    There are few medical insurance schemes in Kenya that specifically target residents of low-income communities.
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RECOMMENDATIONS
i.    Training of more medical personnel such as doctors, nurses, public health officers etc., and deploying a number of them to low-income community areas.
ii.    Working more with community health workers and NGOs to convey health information to the community and sensitize them on proper hygiene methods.
iii.    Introduction of computerized hospital information systems e.g. medical records systems to minimize paperwork and create better management of patient, personnel records and hospital records in general.
iv.    Organizing more ‘barazaas’ (informal meetings) through local leaders e.g. chiefs, to convey to the community health and hygiene information.
v.    Providing health information material to patients and the community at large through various forms of media e.g. pamphlets, fliers, television screenings on health etc.
vi.    Use of medical staff, e.g. nurses, doctors and clinical officers, to impart health knowledge to residents in local dialects.
vii.    Increasing community outreach programmes by the various hospitals and clinics in the country, especially those around low-income communities.
viii.    Coming up with insurance schemes targeting low-income communities and sensitization about existing insurance schemes available to LIC residents.
ix.    Government legislation is required to provide quality medical care but still at a low-cost (affordable to LICs).
SUMMARY
In conclusion, it can be observed that there are still few health centres in low-income community areas. These centres are still faced with a shortage of medical staff even with the ever rising of patients from such communities. However, an encouraging factor is that medical services are available at affordable rates or completely free in some cases.
More still needs to be done in imparting health information and proper hygiene practices to residents of LICs. The government and donor organizations also have to put greater effort in availing more health centres and subsidized medical services in such areas.


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