United Nations Public Service Awards Case Studies

ARVs provision in Kenya started the early 2000’s but this was only limited to private hospitals and clinics where patients or organizations spent a lot of money to access treatment.
In the public sector, (ARVs) provision begun in a limited national referral and provincial hospitals as a pilot. Only 5 sites were covered countrywide. The high cost and limited availability of the services therefore meant that only very few patients could access the much needed antiretroviral therapy (ART).
The major issues to be addressed were related to the healthcare infrastructure in the country such as lack of sufficient appropriately trained health care workers to effectively manage ART patients as this was a new field of practice, lack of elaborate laboratory network for HIV testing, lack of a reliable supply chain management system for ARVs procurement and timely distribution of ARVs countrywide, unavailable national data capture tools for ARVs consumption reporting at healthcare facility level, undeveloped national centralized ARVs data base as well as information management system, lack of patient health management information system and patient’s referral mechanisms.
Lack of various national guidelines(GLs) for example ART treatment GLs, nutritional GLs, prevention of mother to child transmission (PMTCT) GLs, post exposure prophylaxis GLs, voluntary counseling and testing (VCT)GLs, Home based care GLs,

The HIV/AIDs was also still considered a fatal killer disease hence associated with very high levels of social stigma, resulting in reluctance to client enrolment to voluntary counseling and testing (VCT) services to determine knowledge on HIV status and also as one of the entry point to ART access for eligible HIV positive clients.
HIV/AIDs was seen as a disease of the economically poor communities and disadvantaged groups and those who were considered not morally upright, all these factors contributed to lack of disclosure and hence inaccessibility to treatment services.

What is the initiative about? (the solution)
The decentralization of both adult and children ARVs to lower levels of care resulted in an increase in the number of ART sites and increased patient access to ARVs. Qualitatively, the level of care given to patients was enhanced as availability of ARVs was made possible to effectively deliver comprehensive care to patients hence clinical outcomes were improved, decreased morbidity and mortality was evident. There was effective management of ARVs as well at lower levels in terms of ordering, receiving, issuing, storage and use. Measurements for the successes above were quantitatively measured from the monthly reports obtained from the sites indicating an increase in number of patients from all ART sites countrywide. Over the last one year, patients on ARVs country wide increased from 75,000 to the current 170,000 patients. The number of sites offering treatment has also significantly increased countrywide from approximately 150 to over 250 sites. One of the proposed solutions to the above challenges was to decentralize ARVs provision to the lower levels of health care so as to reach as many deserving patients/clients as possible. Decentralization now meant that comprehensive HIV Care and treatment could now be availed not only at limited higher level facilities but also in all district hospital, sub-district hospitals, health centers, dispensaries and clinics. In order to support the above decentralization, a number of activities were carried out for example; improving the existing laboratory network to facilitate HIV testing. Development, printing and dissemination of all relevant national guidelines (ART treatment GLs, nutritional GLs, prevention of mother to child transmission (PMTCT) GLs, post exposure prophylaxis(PEP)GLs, voluntary counseling and testing (VCT)GLs, home based care GLs) was done to all health facilities.

Who proposed the solution, who implemented it and who were the stakeholders?
The above solution was suggested to NASCOP through a national ART taskforce composed of various technical and resource partners as a way of increasing patient/client access to ARVs and also to decongest the few, available and high patient volume ART sites through patient referrals to enable efficient service delivery. This was later shared in an annual ART stakeholders forum among the all in-country representatives from the various partners who carry out HIV treatment and prevention activities in the country under the stewardship of NASCOP . The stakeholders included all direct and indirect partners working in the country in all HIV related activities including prevention, care and treatment, research as well as community linkage support partners. The initiative was later given a go ahead for implementation countrywide by the Ministry of Health through the office of Director for Medical Services. The healthcare workers in all public, private, mission, faith based organizations contributed significantly to the roll out and actualization of this initiative. A new working slogan; rapid results initiative, (RRI) was applied, under the concept of result based management adopted by the various government institutions for improving service delivery in the public sector. There was an immense support from the numerous country/national level and regional partners who came in handy in filling in the various resource and technical support gaps. They include Government of Kenya(GoK),Ministry of Health, National AIDS Control Council(NACC), Public Universities(Moi & Nairobi), Professional associations, Kenya Medical Research Institute(KEMRI),Kenya Medical & Supplies Agency(KEMSA), Mission for Essential Drugs & Supplies(MEDS),all USAID funded NGO’s, all multilateral development partners, Presidents Emergency Funds for AIDs Relief,(PEPFAR), Clinton Foundation, CDC, World Bank, UNAIDS, WHO, UNICEF, MSF’s, JICA, European Union, GTZ, DFiD, Global Funds for TB/Malaria/HIV/AIDs, AMREF, HIV/AIDS lobby groups including organizations for those infected and affected by HIV/AIDs and many others.

Describe how and when the initiative was implemented by answering these questions
a. What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The implementation of the above initiative was systematically implemented through the Ministry of Health infrastructure and NASCOP’s leadership in giving guidelines and coordinating the various partners working in the different regions in Kenya. The strategy employed was through mobilization of both technical and resource assistance from governmental and non-governmental bodies at national, regional and facility level to support the initiative on decentralization among them; • Human resource capacity building through trainings conducted in workshops, seminars and also as on the job trainings, mainly through partner support • Development of a national HIV/AIDS strategic plan and policy by the NACC and partners • Recruitment of additional health care professionals by government and its development partners • Setting up of HIV/AIDS comprehensive care centres to serve clients through the provincial/district health management teams PHMTs/DHMTs • Setting up of additional testing facilities countrywide by NASCOP, faith based organizations, FBOs and key partners • Setting up a reliable, efficient and effective supply chain managers for HIV/AIDS commodities(ARVs, Test kits and condoms) through KEMSA and USAID support • Increased advocacy and communication campaigns to highlight prevention measures for primary infections by NACC and key implementing partners • Setting up of regional/provincial coordinators, provincial AIDS coordinators (PASCOs) ,provincial ART officers(PARTOs) offices, and district AIDS coordinators, DASCOs by NASCOP through the provincial medical offices, PMOs • Laboratory infrastructural support system by the National Public Health Laboratory Services, • Setting up of Regional blood transfusion centres by the National Blood Transfusion Services, NBTS

b. What were the key development and implementation steps and the chronology? No more than 500 words
The implementation of the above initiative occurred via concurrent multiple partner and government efforts. There were partners involved in development of training guidelines and curricula, those who later supported trainings and eventually those who supported treatment activities at facility level. Two main agents, KEMSA and MEDS specializes in procurement and distribution of HIV/AIDs commodities countrywide under NASCOP’s coordination. In-sufficient staffing levels were partly alleviated via recruitment of additional healthcare personnel and posting them to areas with acute shortages to support ART scale up in all districts, sub-district hospitals, health centres and dispensaries. Strengthening of the laboratory services to support regular laboratory monitoring follow up tests of patients, this was achieved by laboratory networking for CD4 tests and Viral load tests through logistical support in sending of dry blood spots (DBS) samples to the various regional accredited labs for analysis and thereafter send back results. NACC and partners carried out national wide media campaigns using print, audio visual, television posters, bill board advertisements to educate and inform the public on ways of HIV/AIDS prevention as well as giving counseling, testing and treatment options available.

c. What were the main obstacles encountered? How were they overcome? No more than 500 words
The implementation of the above initiative encountered and still continue to encounter a number of obstacles and challenges. They include; • Persistent resource gaps in achieving all possible set targets in prevention of new HIV cases, counseling, testing and treatment. Partner support in most instances was sought. • Challenges in achieving national commodity security hence recurrent gaps in supply of key supplies such as ARVs, test kits and condoms. The immediate solutions were to have partner support as the program lobbied for increased government funding. • Staff shortages which necessitated role shifting for health care workers especially the nursing staff who had to take responsibility of managing patients in most health care facilities. • A weak laboratory infrastructure across most health facilities and in-adequate personnel. This obstacle was reduced by laboratory networking in sending of samples and dissemination of results.

d. What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
The resources required for effective HIV/AIDS management were immense and thus required a lot of collaboration among the various partners. National AIDS Control Council, NACC did a 5 year forecast and quantification requirements across all needs which provided a guide on what was required. This worked into millions of dollars These were human resources, infrastructural support, commodity needs and technical needs. The resources were mobilized from all sectors; public, government, private, multilateral development partners, united nations agencies etc. The summary of the total requirements as projected are as below; 2005/06 2006/07 2007/08 2008/09 2009/10 TOTAL PREVENTION OF NEW INFECTIONS Youth-focused interventions 1,017 1,416 1,853 2,341 2,883 9,510 Sex workers and their clients 35 37 38 39 41 190 Workplace 210 278 349 425 503 1,765 Harm reduction programmes 14 20 24 27 31 116 Uniform Services 59 83 109 135 164 550 Other vulnerable populations 118 166 217 271 327 1,099 Condom provision 1,527 2,426 2,747 3,095 3,472 13,267 STI management 422 466 513 561 612 2,574 VCT 740 789 777 830 886 4,022 PMTCT 953 1,363 1,357 1,351 1,450 6,474 Behaviour change communication 240 240 120 80 40 720 Blood safety 365 426 487 548 656 2,482 Post-exposure prophylaxis 40 55 70 85 108 358 Total: Prevention 5,740 7,765 8,661 9,788 11,173 43,127 IMPROVING THE QUALITY OF LIFE Home-based care 265 323 345 380 423 1,736 Palliative care 163 217 116 158 176 830 Diagnostic testing 78 95 113 130 147 563 Treatment of opportunistic infections 1,668 1,712 1,364 1,384 1,249 7,377 Opportunistic infection prophylaxis 117 163 212 261 314 1,067 Lab HAART 55 93 139 173 216 676 ARV therapy 4,000 5,231 7,458 8,352 9,357 34,398 Training 27 39 57 69 81 273 Nutritional support 133 164 259 299 357 1,212 Protection of human rights 723 795 835 835 835 4,023 Total: Improving the Quality of Life 7,229 8,832 10,898 12,041 13,155 52,155 MITIGATION OF SOCIO-ECONOMIC IMPACT Mitigation policy 883 1,076 724 808 1,352 4,843 Mitigation advocacy 1,261 1,537 1,087 808 451 5,144 Livelihood and social security 1,261 1,537 1,087 1,213 1,352 6,450 Mitigation programmes 2,838 3,842 6,881 8,287 10,160 32,007 Community empowerment 757 922 724 808 901 4,112 Human resource planning 252 307 362 202 225 1,348 Total: Mitigation of Socio-Economic Impact 7,252 9,221 10,865 12,126 14,441 53,904 PROVISION OF SUPPORT SERVICES Financing and procurement 770 770 770 770 770 3,850 Communication, coordination & networking 1,514 1,844 1,811 2,021 2,253 9,443 Monitoring and evaluation 1,816 2,459 2,173 1,617 1,802 9,867 Research 505 615 724 808 901 3,553 Institutional capacity building 505 615 724 808 901 3,553 Total: Support Services 5,110 6,303 6,202 6,024 6,627 30,266 OVERALL TOTAL (Kshs. million) 25,331 32,121 36,626 39,979 45,396 179,452 OVERALL TOTAL (US$ million) 338 428 488 533 605 2,393

Is the initiative sustainable and transferable?
The initiative is sustainable to a great extent based on the fact that implementation was done through the existing public health care infrastructure. The health infrastructure has guaranteed continuity from the government annual funding. This therefore eliminates the vertical nature of most new programs which are donor dependent and which most often collapse after donor exit. The decentralization concept is still being rolled out throughout the country and NASCOP hopes to share the concept among other countries in the region.

What are the impact of your initiative and the lessons learned?
The implementation of decentralized system for ARVs provided a useful insight into management of a new program especially that of HIV/AIDS. These include; Need for sector wide approach towards program implementation for a program which cuts across many sectors, touches on socio-economical as well as emotional aspects. For effective HIV/AIDS program planning and implementation, a proper infrastructure is necessary to serve as a backbone in the eventual roll out and continued sustainability of the program. Continuous engagements of key partners through regular meetings and taskforces are necessary for smooth program running. Regional approach towards program implementation achieved greater results than a centrally run program as the regions had a hands on approach to their challenges which required unique solutions.


Institution Name:		National AIDS/STIs Contrl Program
Institution Type:		Government Department
Contact Person:		Ibrahim Dr Mohammed
Title:		Program Head
Telephone/ Fax:		+2542714972
Institution's / Project's Website:		+2542710518
E-mail:		headnascop@aidskenya.org
Address:		P. O. Box 19361-00200
Postal Code:		00200
City:		Nairobi
State/Province:		Nairobi
Country:		Kenya

The Problem

Solution and Key Benefits

Actors and Stakeholders

(a) Strategies

(b) Implementation

(c) Overcoming Obstacles

(d) Use of Resources

Sustainability and Transferability

Lessons Learned

Contact Information