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Improving iron and folate supplement availability for Antenatal Care in Kenya

Improvement Report
Michael Mwaniki Kivwanga, Sonali Vaid, Evelyn Kamgang, Dorcas Amolo, Youssef Tawfik

Topics: Antenatal care, Country ownership, Employee Engagement, Equipment/supplies, Financial management, Maternal nutrition, Micronutrient supplementation, Sustainability

Region and Country: Kenya

Organization: USAID Health Care Improvement Project/URC
The Report

Realizing the importance of Antenatal Care (ANC) Services in improving maternal and child health, the Kenya Ministry of Health and the USAID Health Care Improvement Project (implemented by University Research Co. LLC) initiated an activity to improve the quality of antenatal care in Kenya. In agreement with other stakeholders, we decided to launch this activity in a rural district which was performing below the national average in the utilization of ANC/Preventing Mother-to-Child Transmission (PMTCT) of HIV services and was relatively easy to access. Based on these broad criteria, Kwale (Matuga) district was selected as the pilot district for this activity.

Kwale (Matuga) district is one of the poorest districts in Kenya (Ndeng'e, Opiyo, Mistiaen, & Kristjanso, 2003). It is located approximately 45 Kilometers south of the city of Mombasa on the southern coast of Kenya. The population is estimated to be 156,450 (2009). According to the district health information management records, maternal mortality rate in the district, is estimated at about 590-700 per 100,000 live births against the national estimates of 490 per 100,000 live births (UNICEF, 2009). The estimated number of women of reproductive age is 37,548, with the estimated number of pregnancies 6,258 annually. Overall, the utilization and quality of Antenatal Care (ANC) in the district is poor with most of the mothers starting ANC late (>28 weeks gestation) and only 25% completing the recommended four visits. This scenario makes it difficult to meet the ANC standard of care. The pilot phase for the improvement of antenatal care in Kwale (Matuga) district began in January 2011 and is expected to continue till June 2012. The aim of the activity was to improve the coverage and quality of ANC services by using quality improvement approaches to institutionalize better care practices.
In Kwale, the quality improvement (QI) teams were established at all the 21 public health facilities in the district. These teams are formed at facilities which then learn to interpret the data collected at the facility-level and use this data for decision-making and improvement of services. Teams at various facilities test changes to improve care.Each of these teams had 3-8 members including health facility staff (nurses and physicians) and community representatives (community health workers, traditional birth attendants and community leaders). These teams were then tasked with reviewing the facility data on 20 ANC/PMTCT indicators (includingtesting for anemia, iron and folate supplementation, tetanus immunization, provision of anti-malarials, screening for pre-eclampsia, HIV testing and counseling, to name a few) to gain an understanding of the current levels of utilization and quality of services at their respective facilities. Upon analyzing their data for the past few months, the teams realized that a very low number of pregnant women were receiving their three-month supply of iron and folate supplements during their ANC visit. This data prompted awareness of a gap in service provision among the district health management teams as well as the facilities quality improvement teams. Further enquiries with the district staff revealed that this was due to the lack of supply of these essential drugs from the national drug supply chain for almost two years.

 The USAID Health Care Improvement (HCI) Project initiated discussions with local officials of the Kenya National Medical Supples Agency (KEMSA) to understand why the supplies of these essential drugs had stopped for nearly two years. During discussions with KEMSA, it was understood that there was a procurement problem at the national level. The national drug supply agent had decided to stop procurement of single iron sulfate and folate tablets and had opted for a combined formulation. However, no supplier responded to the tender for the combined formulation, this resulted in an acute shortage of hematinics in the national supply. Upon learning about this bottleneck, HCI initiated dialogue with both the national supply agency and the departmental heads in charge of essential drugs and commodities supply at the Ministry of Health and advocated for resolution of this issue. As a result of the ensuing dialogue, the issue of shortage in hematinics supply was highlighted at national level. However, it was also clear that it would take about a year or more for the national supply to resume. 

Realizing that the national supply would take time to resume and that it would not be acceptable to give women sub-standard care in the interim, each QI team devised a plan to purchase hematinics locally to meet the needs of pregnant women while waiting for the national supply to resume. Each facility in Kwale collects a small service charge for certain services at the facility. These funds are to be used to improve services at the facility-level and are directly controlled by the facility management committee which also includes members of the QI teams. Facility QI teams decided to prioritize the use of these funds to purchase hematinics at the local-level.
Additionally, the QI teams ensured that ANC mothers were educated during each visit on the need to take the hematinics and on how to minimize common adverse effects that hinder compliance, chiefly nausea, vomiting and constipation. Monitoring of stock levels of hematinics was also initiated to ensure timely ordering of new supplies to avoid stock outs. This was done through daily updating of the available stock control books at facility pharmacies.



Data was collected and reviewed by QI teams from facility ANC registers on a monthly basis and a noticeable improvement in the number of women that received hematinics during ANC visits was observed. From March 2011, when the quality improvement teams initiated the aforementioned measures to the end of July 2011, close to 80% of all mothers receiving ANC received folate compared to 40% in February of the same year. The number of mothers receiving iron sulfate also doubled (from <20% to 46%) during the same period. The improvements continue to be sustained and by November 2011 more than 80% of women were receiving the recommended iron and folate supplements.  (fig 1 in the “Related Documents” section)


This improvement experience emphasized that the provision of quality ANC is dependent on various factors such as regular supply of iron and folate supplements. It is possible to strengthen these factors, as seen through the work of the USAID HCI Project in Kenya, by targeting  all levels of the health system in a coordinated manner - local facilities, regional and national levels. By so doing, we were able to improve the supply and utilization of hematinics. The results suggest that applying QI approaches can improve the availability of essential drugs.

Additionally, this improvement experience demonstrates the importance of the use of data for decision-making at the facility-level. Using the data instead of just collecting it for reporting to higher levels can enable managers of small health facilities to take actions to address gaps in care, such as purchasing essential drugs in the absence of a national supply. This can ensure that services do not collapse when bottlenecks arise at the national procurement level. It is worth noting that about one third of the members of the Quality improvement teams are also members of the facility management committee which manages the facility budget, demonstrating the importance of involving decision-makers in quality improvement efforts.
With these lessons in mind, it is important to highlight that despite our initial successes in procuring these essential drugs at the local level, facilities are still awaiting supplies from KEMSA to normalize. Moreover, the coverage of pregnant women receiving a 3-month supply of folate and iron still has not increased to 100%. The QI teams have put in more effort to increase this coverage as well as improve compliance with the iron tablets along with other aspects of ANC/PMTCT services.

This case report has a limited sample size and generalizability, but it showcases the importance of working across all levels of the system and the use of data for decision making at all levels. Quality improvement activities are often hampered by challenges of irregular supplies. It is hoped that this case study will provide impetus to quality improvement activities to surmount some of the challenges of supplies and equipment by applying the same methodologies they use to improve compliance with service delivery standards.