Kenya Project

 Kenya Project Baraka Health Centre Baraka Health Centre was started in 1997 and is located in Mathare Valley, the 2nd largest slum in
Nairobi, situated in the Northeast of town. It serves mainly the population of the slum and surrounding
areas (see map of the catchment area) but also attracts patients from further away.
The Health Centre is comprised of the
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General Health Clinic
Feeding Centre
Comprehensive Care Clinic (care for patients with HIV and/or TB)
Community Based Service
Vision, Mission, Core Values Vision Improved health, nutrition status and quality of life for the Mathare community.
Mission We envisage providing high quality and affordable medical services to the people of Mathare as
well as creating an environment for prevention and awareness for a healthy living in order to
make them the custodians of their health.
Core Values: -
Competency & Professionalism
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Efficiency & Effectiveness
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Respect & Compassion
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Confidentiality
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Integrity & Equity
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Transparency & Accountability.
Project Background and Target Group Conditions in the target area Mathare Slum is the second largest slum in Kenya and is located in the Northeast of Nairobi. The
population size is appr. 443,000 people in 139,000 households, whereby a household is defined as
a group of persons sharing the same income sources and eating together. The average family size
is 3.9 for the whole slum area.
Mathare Valley can be divided into four levels: 1) The “better off” have their stone houses near
the main road. They look much more prosperous than the shanty huts and have rooms for small
businesses and living quarters. 2) The “middle class” have a combination of stone structures and
shanty mud huts or iron sheets. 3) The “poor” live in iron-sheet structures built by individuals
and in tiny mud shanties. 4) The “very poor” occupy the bottom of the valley along the river in
dwellings that are tightly squeezed together and usually blown over or destroyed during the rainy
season. Entire families are sometimes swept away by the river. Waste from the upper-level
buildings rushes down into the valley, adding to the accumulation of filth and human excrement.
Kenya Project 2 / 17 Insufficient hygiene and sanitation facilities continue to be the main vulnerability factors.
Drinking water is not available in the huts. It must be bought in bottles. There is no electricity
available for the “poor”; fire wood and charcoal are used for cooking.
In terms of employment, about 56% of the households have casual jobs or small-scale
businesses, and 13% have regular jobs. Unemployment is high among the slum population, and
the presence of an unemployed member in a household is strongly correlated with poverty.
Under/unemployment is a common problem among single fathers, youth, and bachelor men and
ladies and is blamed for high crime rates, especially in villages like Kosovo and Village 2, where
67% - 80% are involved in criminal activities (e.g., burglaries, shoplifting, robbery, smuggling of
stolen goods, mugging, hijacking, etc.).
Mathare Valley slum has experienced a huge amount of violence throughout the years. On all
levels – social, political, and economic – the slum population has been left behind with no
perspectives. Coping strategies, such as prostitution, criminality, or brewing of alcoholic
beverages are widespread among the entire population. Single mothers and children make up the
most vulnerable social categories and many of them are forced to practice prostitution as the
main source of income (an average of around 30 to 50% in both categories) with the
accompanying high risk of getting and spreading HIV/AIDS.
A big part of the population is migratory: depending on the socio-economic situation people
move from Nairobi to “up-country” and back.
Kenya Project 3 / 17 Community (Mathare) -
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Mathare is the 2nd largest slum in Kenya, located in the North-East of Nairobi, 7 km from the city
centre. It is bordered with Thika road in the North, Juja road in the South, OuterringroadKariobangi, Babadogo Estate in the East and Pangani Estate in the West.
It started in pre-independence with informal settlement and has currently a population size of around
440,000 people in 139,000 households. There is a high rate of unemployment: 13% have regular jobs,
56% casual jobs or small scale business. This is associated with a high poverty level with the
consequence of a high crime rate and prostitution on one side and a poor nutrition status on the
other.
Insufficient hygiene and sanitation facilities are main vulnerability factors. Drinking water is not
available in many huts. It must be bought in bottles. There is no electricity available for the “poor”;
fire wood and charcoal are used for cooking.
A big part of the population is migratory: depending on the socio-economic situation people move
from Nairobi to “up-country” and back. Further problems include substance and alcohol abuse.
The vision of Baraka Health Centre is improved health, nutrition status and quality of life for the
Mathare community.
The general health clinic Six German Doctors work as volunteers and usually stay for 6 weeks: when 1 doctor leaves a new one
comes in. The other staff members are Kenyans: 12 professional staff like nurses, clinical officer, lab
technologists, pharmacists and counselors as well as 25 support staff.
Daily 250-300 patients are seen during clinic hours from Mondays to Fridays (excluding public holidays)
from 8.00am to 4.00pm.
The clinic is the entry point for the -> Feeding Program and the -> Comprehensive Care Clinic (= CCC,
i.e. the HIV- and TB-clinic).
Services provided include:
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All curative outpatient services (also depending on the specialist skills of the doctors present)
Laboratory services
Ultrasound scans
ECG (1-channel)
Pharmacy
H.T.C (= HIV-testing and counseling) and other counseling services
Small theatre for minor surgery like incision of abscesses, wound management, sutures, infusions,
nebulization.
Pay for x-ray services
Daily health education to patients
Palliative treatment for patients with life limiting illnesses like cancer. This includes the provision of
morphine for severe pain as well as moral and psychosocial support. There is a close link to the
community team for home based care.
Kenya Project 4 / 17 Common conditions seen include:
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TB - seen at the Tb clinic in our facility, lab reagents and medication are provided by the
government of Kenya (GoK)
HIV - referred to our CCC if from our catchment area or other respective sites
Malnutrition – referred to the Feeding Program
Acute diseases like common colds, pneumonia, diarrhoea and vomiting
Gynaecological, urological and sexually transmitted diseases
Fractures, injuries, burns
Infectious skin diseases
Chronic diseases like diabetes, hypertension, asthma, epilepsy, sickle cell disease
Cancer and other diseases requiring palliative care
We have a united team that is always ready for our clients
Kenya Project 5 / 17 The Feeding Program The Feeding Program was started in 1998. It is located approximately 100 meters from the General Health
Clinic and acts as a referral site for the this clinic, the HIV-/AIDS Clinic (also called “Comprehensive
Care Clinic” or CCC) and the community for all the patients who require any nutritional intervention. It
has the following programs:
Malnutrition program is one of our biggest achievements with a recovery rate of 82.5% in the year 2011
for severe acute malnutrition. We partner with Concern Worldwide, World Food Program and UNICEF
to run the malnutrition program. This program caters for children between 6 and 59 months with severe
acute malnutrition without medical complications and for children with moderate acute malnutrition.
Malnourished patients are assessed using anthropometric measurements and clinical observation.
Outpatient Therapeutic Program (OTP) for severe acute malnutrition:
Those who fit the criteria of
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<-3 Z- Score,
MUAC < 11.5 cm and / or
oedema +
are admitted to the OTP. They are issued on a weekly basis “Ready to use Therapeutic Food” (RUTF)
which is peanuts based and commonly referred to as “Plumpy Nut”. The quantity is individualized
according to the child’s weight. 431 children were treated with Plumpy Nut in 2011.
Supplementary Feeding Program (SFP) for children with moderate acute malnutrition or
malnourished pregnant or lactating mothers:
The following are recruited:
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children weaned from OTP,
children with a MUAC >11.5 cm and < 12.5cm or >-3 Z-Score to <-2 Z-Score or
pregnant and lactating women with a MUAC < 23 cm.
These patients are issued corn soya based porridge flour that is premixed with cooking oil at the facility.
The food is issued every fortnight and each patient receives 4.1 kg. This program started in June 2011.
Unfortunately the supply with flour has not been sustainable so far. Alternatively patients can be admitted
to our “Wet-feeding Program” (see below).
Kenya Project 6 / 17 BEFORE ADMISSION
AFTER RECOVERY
Kenya Project 7 / 17 The Replacement Feeding Program caters for the nutritional needs of infants who are issued formula
milk for eight months.
They fall under two main categories:
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HIV exposed infants whose mothers have chosen exclusive replacement feeding after thorough
counseling at our Comprehensive Care Clinic and have met the AFASS criteria (accessible, feasible,
achievable, sustainable and safe) or
Orphaned and vulnerable children.
98 children were treated in 2011 and successfully discharged after 8 months.
This program is wholly supported by the German Doctors. The formula milk is issued weekly and infants’
growth monitoring done monthly.
This child completed eight months on formula milk.
The Wetfeeding Program is sponsored by the German Doctors and supports one feeding centre and
four schools. In co-operation with the “Drought Response Program” by GIZ we received additionally
funds for up-scaling the number of patients during the period from November 2011 to April 2012.
At the feeding centre patients are admitted according to a number of categories which include
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weak HIV/TB patients who are on treatment in our catchment area,
moderately malnourished children < 5 when the supply of flour in the SFP is not sustainable (see
above)
moderately malnourished adults and children who do not fit the SFP criteria and
social cases which include orphans, vulnerable children, the elderly and children of patients in our
Comprehensive Care Clinic.
The patients are served with a plateful of a balanced meal comprising of rice, beans or greengrams and
vegetables.
Kenya Project 8 / 17 At present almost 200 adults and 400 children are supported in the feeding centre and more than 700
children are supported in the four schools.
Treatment of rickets: During the last few years the prevalence of rickets has grossly increased. 250
children underwent a six week rickets therapy with daily Vitamin D and Calcium distribution in 2011.
Nutrition education and counseling are services offered to our patients on various health concerns
including preventive and curative measures of common health conditions such as hypertension, diabetes,
diarrhoea and vomiting, malnutrition, antenatal and postnatal health practices.
More so infant and young child feeding practices are emphasized from child birth where mothers are
encouraged to practice exclusive breastfeeding and appropriate introduction of complementary foods at
six months. To facilitate the implementation of the healthy child care practices mothers are taught and
demonstrated proper positioning and attachment of the child during breastfeeding and attend cooking
lessons using locally available and affordable foods.
The Feeding Program has contributed a lot in ensuring adherence to HIV and TB treatment. In addition it
has helped to prevent adverse effects of malnutrition. We are committed to be part of rising a healthy
generation in Mathare Slums.
DANKE, GERMAN DOCTORS
Kenya Project 9 / 17 Baraka Comprehensive Care Clinic Baraka Comprehensive Care Clinic also referred to as Referral Clinic is located in Mathare area three. The
start was made in 2001 with the provision of VCT-services. In 2005 it opened its doors to HIV patients as
a satellite of Nazareth Hospital. In 2008 it became fully fledged partly sponsored by PEPFAR (=
President’s Emergency Program for AIDS Relief) through AIDSRelief, a consortium of several USAmerican mainly Christian organizations.
SERVICES OFFERED 1.
2.
3.
Voluntary counseling and testing (= VCT)/ diagnostic testing and counseling (= DTC).
Over the years the need for testing has increased with HIV awareness and advocacy done, but many
people especially in the slums are yet to be tested. In 2011 14,088 patients were tested, 1,663 turned
HIV-positive (10.4% of men and 12.8% of women). National prevalence stands at 6.3% and Nairobi
province at 7%.
Provision of adult/ pediatric HAART/ opportunistic infections drugs. The clinic has at present
more than 2,200 patients enrolled with > 1,800 on antiretroviral therapy of which 62% of the cohort
are women and 38% men. There are around 320 children enrolled in the program out of which 130
are on HAART. The percentage of children on HAART is rather low (7%) due to a late start of
pediatric HIV-care (in 2007) and other programs in the neighborhood which focus on pediatric care.
PMTCT (prevention of mother to child transmission) for women in our program who get
pregnant. It was started in September 2007. Apart from antiretroviral therapy (= ART) for mothers
and babies we give mothers the informed choice of exclusive breastfeeding or exclusive replacement
feeding. If they chose to replacement feed we provide them with formula milk free of charge
including a lot of teaching and follow-up on hygienic preparation.
Since the start we cared for more than 250 PMTCT mothers. 130 children were/are breastfed, 121
children replacement fed. 147 children are meanwhile > 18 months old with 114 HIV-negative, 17
transferred out or lost to follow-up, 9 deaths and 7 HIV-positive. There is no significant outcome
difference between the breastfed and the replacement fed cohort.
Since July 2011 we provide antenatal services for our PMTCT-mothers including all updated
immunizations for their children in collaboration with KEPI (Kenya expanded program on
immunizations in Kenya).
Kenya Project 10 / 17 4.
5.
6.
Community based program. Nurses, a social worker, adherence officers and community volunteers
follow up patients in their respective homes (see special chapter).
TB (tuberculosis treatment). We cooperate with the Government of Kenya which provides TBdrugs and lab reagents. In 2011 we diagnosed 443 patients with TB and treated 334 in our facility
with around 70% being co-infected with HIV (the high percentage of HIV-co-infected patients is
due to the fact that we offer integrated HIV-care.)
Support Groups: At present we only have a support group for HIV-infected children and one for
PMTCT-mothers. An up-scaling is planned for 2012. In addition other players/partners in the
catchment area are holding support groups which many of our patients attend.
Kids Club/ Support Group for HIV-infected Children: The objective is to develop a therapeutic
relationship with guardians and children and increase disclosure.
April 13th 2011-Judy and the kids drawing
PMTCT-Support Group: The objective is to prepare antenatal mothers for the feeding
options, care of the newborn, family planning and how to overcome challenges they might
face.
Kenya Project 11 / 17 Achievements/Successes 1.
Effective use of containers in a limited resource setting
Container clinic before the move
After the move
Containers if used and partitioned well can make a wonderful clinic. Above are various rooms in our
clinic: consultation rooms, pharmacy, acute room, data room.
Kenya Project 12 / 17 Inside we have partitioned accordingly:
Data room /Archive
2.
Pharmacy with booths
Participation in conferences and linkage with national and international stakeholders
Elizabeth and Rose Omia presenting a poster on coding of patients’ files at the 1st National Biennial Conference held in Nairobi in May 2011.
Kenya Project 13 / 17 3.
Colour coding of files: Files of men, women, whether on HAART or on prophylaxis, children,
PMTCT mothers have different colors. This has attracted many stake holders who emulate it in their
programs. It is a good way of ensuring efficient and effective file management, limiting time wastage
and enhancing a good filing system.
4.
5.
Baraka CCC won an AIDSRelief award in 2009 for continuous quality improvement.
Strong emphasis is put on tracking and testing family members of our HIV-patients by development
of a family tracking form. On every patient’s visit we can review this form to ensure that all family
members get tested.
Successful adherence monitoring with less than 3% (= 40) of the total cohort of patients (1820)
changed from 1st to 2nd line treatment since HAART was started (refer to community monitoring).
6.
Kenya Project 14 / 17 COMMUNITY BASED SERVICE -
Community based care is provided for 11 small “villages” in Mathare and outskirts linked to Baraka
Health Clinic, the Feeding Program and the Comprehensive Care Clinic.
The Community Department has 1 social worker, 3 nurses, 3 adherence officers and 40 active trained
CHWs (many of them being HIV-positive) who work as volunteers.
Tasks -
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Follow-up on HIV- and TB- patients as well as children with malnutrition. This includes treatment of
minor illnesses, de-worming and referral of sick patients to the clinics.
Active case finding for children with severe acute malnutrition (SAM) including MUAC- (= mid
upper arm circumference) screening, for people with TB by history taking and for HIV through
home testing.
Contact tracing of family members of TB-infected patients
Defaulter tracing of patients missing appointments in the HIV- or TB-clinic*
Adherence monitoring through pill count and adherence counseling.
Counseling on acceptance, disclosure, hygiene, nutrition, safe sex.
Assessment of the social status/background of patients
Follow-up on PMTCT-mothers and their infants: referral of all HIV-positive pregnant women to an
Antenatal Clinic and check on infant feeding methods.
Palliative care for patients with limited life expectancy.
Economic empowerment through small IGAs (= income generating activities)
Advocacy on HIV-prevention by outreach activities to schools and different places in the slum for
health education, VCT (= Voluntary Counselling and Testing)
Training and capacity building of CHWs, TBAs (= traditional birth attendants), village leaders,
youths and herbalists on health related issues.
Linkages, cooperation with and referrals to other local partners e.g. GoK, Faraja Trust, WFP,
COOPI, Harvest, Feed the Children, Nyanza Health Production for VMMC, MSF (= Médecins sans
Frontières) for patients suffering from gender based violence.
*How do we trace defaulters?
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The data people at the CCC generate a list of planned appointments.
Files are taken out prior to the visit.
The following morning files for those who failed to attend the clinic are handed over to the
community team.
The community team tries to reach these patients on the phone. If unsuccessful physical tracking (i.e.
home visit) is done.
Contacts are updated on every clinic visit. Newly enrolled patients are linked to a CHW who does a
home visit
Kenya Project 15 / 17 Achievements 1.
2.
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6.
Defaulter rate was reduced.
Improved adherence:
a. increased punctuality in keeping appointments
b. increased punctuality for routine check-ups like CD4s and PCR.
Earlier presentation to health services by good established network of CHWs, home visits, outreach
services and community awareness, active case-finding, early detection and referral for illnesses.
Improved integrated services by networking with other partners like Faraja and COOPI for social
issues and economical needs, Harvest, WFP, Feed the Children for malnutrition, MSF for gender
based violence, GoK for monitoring, evaluation.
Reduction of pain and suffering by provision of palliative care (provision of morphine and trained
personal in pain management and TLC (= tender love and care))
Capacity building on health related issues through training of CHWs, village elders, the youth, TBAs
and our patients by health talks.
Challenges 1.
2.
3.
4.
5.
Migrant character of the population hence difficult to trace defaulters, lots of transfers in and out.
High poverty rate leading to poor nutrition status as well as prostitution, alcohol and substance abuse
hence high risk of acquiring HIV/ AIDS.
Poor hygiene/refuse disposal water and sanitation, overcrowding leading to recurrent infections like
diarrhea and TB.
Many patients rely on casual jobs. These are often interfering with their clinic appointments.
Late presentation of many patients when they are sick.
Clinic Committees In order to provide an efficient and effective running of the clinics, the best possible care for our patients
as well as a safe and enjoyable environment for our members of staff there are several committees in
place:
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Management team: advises the board in Germany on decision making and is responsible for the
smooth running of the health centre in all aspects: financially, administratively and clinically.
Infection prevention control committee: is responsible for implementation and monitoring of
proper infection prevention control in accordance with the Ministry of Health guidelines.
Drug therapeutic committee: ensures rational drug use: that patients are provided with the best
possible cost-effective and quality of drugs.
Continuous quality improvement team of the CCC: ensures that quality of care is maintained
throughout the clinic and all services conform to WHO- and Ministry of Health-guidelines. In
addition it monitors the other committees.
Adherence Committee of the CCC: ensures that the highest possible number of HIV- and TBpatients is adherent to their treatment. It does e.g. proper screening of patients especially those
transferred from other clinics who often have been defaulters.
Resource mobilization committee: supports patients with desperate social needs.
Social Fund Committee: addresses the social needs of our members of staff.
Kenya Project 16 / 17 Acknowledgements 1.
2.
3.
4.
To the German Doctors for the support they have given us.
To all our stakeholders
To all members of staff for their commitment at work
To the local administration of Mathare and the community in general.
Baraka Team
Baraka Team
Kenya Project 17 / 17