COMMUNITY

HEALTH
(1)
Lecture notes
Written by Michael Mutisya Msc public health (jkuat)

UNIT II : PHC & CBHC 30 HOURS

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 LESSON 1:
PHC:Introduction; Definition (WHO);Evolution of PHC, PHC elements; Principles and pillars of PHC;
impact of PHC

COMMUNITY HEALTH
MODULE 9
Code CMH 1104
Hours 30
Credit 3
INTRODUCTIONS
This module is designed to equip the learner with knowledge, skills and attitudes in working
with communities to prevent and manage injuries and disabilities

COMMUNITY HEALTH
DEFINATION
hiIs apart of health care that is concerned with the health of the whole population and
prevention of diseases through community participation.
It involves:
 Establishing the health status of the community
 Planning for community services
 Managing and utilizing health facilities
Community health care focus is in the population and how specific social determinants of
health and disease influence well being.

Community health emphasizes how well the community can be mobiles do and empowered to
improve on the conditions within their homes, behavior, social cultural interaction , effective
use of resources so as to achieve the best possible level of well being.

The term community health also refers to :

 Population medicine
 Social medicine
 Community medicine
 Preventive medicine

Research has shown that prevention of diseases, health promotion and effective rehabilitation
has far reaching positive effects in health and social economic activities.

What is a community?
Is a group of people (a large or small group) living in certain geographical area working together
for a common goal. It shares the same resources water,climate, and geographical conditions
health services administration and leadership.
Community is made up of the following:

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 a) INDIVIDUAL: Each individual is unique being where he separate and district from all
other human beings.
However, each person shares behavior characteristics with other people who are part of
particular culture.
Culture is all those things which people learn ,share and pass on to later generations e.g
language. As a health worker, you must be able to communicate effectively. When
working in a place /area where a language other than their own is spoken,knowledge of
the the language will be vital to their work.
It is important to be able to show respect and understanding for other people and their
culture, not merely knowing the local greetings.
We learn our believes and customers about right and wrong aw we grow up. Some
practices and beliefs about sickness and health are related to those belief in ancestors
or in the power of people to perform witchcraft.
b) FAMILY: is a group of two or more persons who share emotional bonds and material
things, usually live in the same house hold, are related by blood, marriage, adoption and
sexual relationships are approved by the parents.
The family is very important social groups in community. Family provides love, security,
and a sense of belonging for individuals from the time they are born .
There are different types of families:
 Nuclear family
 Extended family
 Single parent family
 Blended family
CHARACTERISTICS OF A HEALTHY COMMUNITY
i. Safe healthy environment relatively free from natural and man-made hazards
ii. Community members value hygiene
iii. Clean water
iv. Nutritious food
v. Available and utilization of health facilities
vi. Available and accessibility of suitable educational,social and recreational facilities
vii. Gainful occupation
viii. There is sound communication structure
ix. Communal and participatory approach when tackling community problem

PROBLEMS THAT AFFECT THE HEALTH OF THE COMMUNITY

 Unsanitary environment
 Overcrowding
 Poverty
 Unclean and inadequate water supply
 Lack of nutrious foods
 Epidemic and endemic disease
 Unstable family life
 Illiteracy and ignorance
 Poor leadership and lack of participation

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  Poor I fracture
 Political instability
PRINCIPLES OF COMMUNITY HEALTH
PRINCIPLE: is a basic belief, theory, or rule that has a basic influence on the way in which
something Is done..
Principles of community health were declared at Alma Ata international conference in 1978
Alma Ata declaring
I. Availability of health care for all people and at a cost they can afford
II. Pro motive and preventive aspects of health care
III. Integration of curative and preventive services
IV. Active participation of individuals and communities in the planning and provision of care
V. Development of maximum potential for self care
VI. Utilization of levels and types of community power
VII. Inter-sectorial approach

PROCESS AND ORGANIZATIONS OF COMMUNITY HEALTH CARE

A comity is made up of various subsystems, all of which have a bearing on how people live and
behave
1) SOCIAL-CULTURAL SYSTEM: This is mode of customs and beliefs, family and kinship,
leadership,and power structure. Some cultural believes promote health but others
don't.
2) POLITICAL SYSTEMS: Government and its development policies as well a political
organizations. There are policies which promote health and the political all support must
influence.
3) ECONOMIC SYSTEMS: For essential health, the economy must be good and the country's
GDP must be stable. Low economic status means malnutrition and communicable
diseases.
4) EDUCATION SYSTEMS: Education is the main tool of changing behaviors and improving
individual and community health. Low education status perpetuates to underdeveloped,
harmful traditions and superstition.
5) RELIGIOUS SYSTEM: May be a source of health promotion when its values and teaching
positively influence lifestyle behavior like forbidding smoking,premarital sex ,alcohol
consumption.
6) ENVIRONMENT SYSTEM: Environmental sanitation is one of the leading promoters of
individuals do community health. This includes clean water supply,proper waste
disposal and adequate housing.
7) COMMUNICATION AND TRANSPORT: Communications includes all the means of
contacting and exchanging information with one another such as roads,bridges,
phones,Internet for this is important for spreading health messages and services.
8) HEALTH CARE SYSTEMS: The health care systems exists to provide promotive,
preventive, curative and rehabilitative services in hospitals,nursing homes clinics health
Centre’s. The health care system is enhanced through linkages that bring together
National government,county government, NGOs, faith based organs and privates in
providing continuous and comprehensive health services.

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 AIMS AND GOALS OF COMMUNITY HEALTH
AIMS
 Improve sanitation in the environment
 Prioritization of comment health needs
 Control of communicable and Non-communicable disease
 Health education to promote health behaviors and practices
 Early diagnosis and prevention of diseases
 Disease surveillance
 Case/contact tracing
 Empowerment of all individuals to realize their rights and responsibilities for
attainment of good health for all.
GOALS
 Identify community health problems and needs.
 Plan ways of meeting community health needs.
 Implement activities geared toward meeting the community health needs.
 Evaluate the impact of community health services activities.

Lesson 2

PRIMARY HEALTH CARE

DEFINATION :

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Background of PHC
In the 1977, World Health Assembly, the government of Kenya along with other member states
of WHO, endorsed the worldwide social objective of 'The attainment by all people of the world
by the year 2000 of a level of health that will permit them to lead a socially and economically
productive life' (WHO, 1977).
However, many countries in the developing world recognized the fact that it was not possible in
the foreseeable future for them to achieve this worldwide social objective. This was because
many lacked the resources needed to develop and run health services. They needed to adopt a
strategy that allowed them to use the available resources to give some benefit to everyone and
provide special attention to those at high risk. The member governments endorsed the PHC
strategy for the provision of health services for all.

The strategy for the implementation of PHC was adopted by the Kenya government to provide
health services to its population, the majority (80%) of whom live in the rural areas.
Definition of PHC

In 1978, the Alma Ata international conference on PHC defined primary health care as:
'Essential health care based on practical, scientifically sound and socially acceptable methods
and technology, made universally accessible to individuals and families in the community
through their full participation, and at a cost that the community and country can afford to
maintain at every stage of their development in the spirit of self-reliance and self-
determination.

From the definition, you need to note the following key statements which identify PHC as
essential health care. These are:
• PHC is universally accessible to individuals and families in the community.
• PHC is socially acceptable to all, meaning that the health care is appropriate and adequate in
quality to satisfy the health needs of people, and is provided by methods acceptable to them
within their social cultural norms.
• PHC is affordable, that is, whatever methods of payment used, the services should be at a
price the community can afford.
• PHC promotes full participation of individual, families and communities.
• PHC is appropriate technology that is, the use of methods and technology which use locally
available supplies and equipments.

Elements of PHC
In the Alma Ata conference of 1978, eight essential elements of PHC were identified. However,
individual countries were given the liberty to add any other elements they felt were relevant to
their own country. Kenya has added other elements.
List the eight essential PHC elements defined at the Alma Ata conference.
The PHC elements listed at the Alma Ata Declaration were as follows:
1. Education concerning prevailing health problems and the methods of preventing and
controlling them

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2. Local disease control
3. Expanded programme of immunization
4. Maternal and child health care and
family planning
5. Essential drug supply
6. Nutrition and adequate food supply
7. Treatment and prevention of common
diseases and injuries
8. Safe water supply and good sanitation
Use the acronym 'ELEMENTS' to help you remember these eight elements.
The Kenyan government has added additional PHC elements to the ones identified at the Alma
Ata conference These are:
• Mental health
• Dental health
• Community based rehabilitation
• Malaria control
• STI and HIV/AIDS prevention and control

1) Health Education:Health education is education that is intended to have a positive

impact on health. It is a process of dialogue with community members to find out
appropriate responses to health problems, as well as to empower them with the
knowledge and insight they need, to understand how their behavior affects their health.
Health education today has extended its scope beyond disease prevention and control
to health promotion. It gives individuals and communities the incentive to promote the
conditions that maintain good health. You can see that health education is an integral
part of all health services, all health personnel including yourself have an important role
to play in organizing appropriate health educational programmes at all levels in the
community.
2) Promotion of Food Supply and Proper Nutrition: Nutritional deficiency states are
particularly noticeable among pregnant and lactating mothers, infants and children. This
may be due to the prevailing cultural or economic factors in the community.
3) Water Supply and Basic Sanitation :Safe water and sanitation is not available to a major
section of our population, yet, it is essential for life. Many water borne diseases which
are prevalent in the community can be prevented if communities gain access to safe
water and adopt proper refuse and faecal disposal. So under this element, effort is being
made to bring together the different factors from related sectors to survey and identify
sources of safe water and carry out proper analysis of the water. At the same time,
community health workers should educate community members on how to protect
wells and springs from contamination, how to construct latrines, compositing facilities
and soakage pits.
4) Maternal and Child Health and Family Planning: Children make up one-half of the
community and their mothers another fifth. On numbers alone, health care for mothers
and children forms the greater part of community health. Mothers and children also run
a great risk of injury and disease because their lives are concerned with beginnings and

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 growth. MCH/FP services are therefore aimed at promoting the health of mothers and
children, by reducing the maternal and child mortality rates, and enabling women of
childbearing age to have the desired number of pregnancies and at the right interval.
MCH/FP care has the following four main functions:
• Antenatal care / Prenatal care
• Perinatal care
• Postnatal care
• Family planning
• Since 1980, the issue of family planning has gained momentum and highlighted
an issue that was formally regarded as unimportant. In response, our
government established the National Council for Population and Development to
coordinate all population and family planning activities. It also set up the service
component of the family planning program within the Ministry of Health. Also,
NGOs such as FPAK, CHAK, and the Catholic Secretariat play an important role in
both motivation and service provision.
• The practice of family planning is an old African tradition. What is new is the
variety of methods which have been introduced to prevent or delay
pregnancy.ImmunizationKenya has for some time now implemented
immunization activities through the Kenya Expanded Programme on
Immunization (KEPI). Immunization is a very effective means of primary
prevention against certain endemic and epidemic diseases. Kenya has a long
history of immunization programmes.Health workers have been trained on
how to motivate and encourage mothers to bring their children for
immunization, as well as how to identify suspected cases of immunisable
diseases such as, measles, poliomyelitis and neonatal tetanus, using
standardized case definition (disease surveillance).

6)Local Disease Control

There are many endemic diseases in this country, some of which are confined to particular
areas. Can you remember what an endemic disease is?
Write down the definition of an ‘endemic disease’ and give some examples of these in Kenya
An endemic disease is a disease which is present in a community all the time.
Examples of endemic diseases in Kenya include the following:
• Malaria
• Schistosomiasis
• Filariasis
• Hookworm
• Trachoma
• Onchocerciasis
As you can see, these are mainly communicable diseases. You will learn more about them.
Malaria Control

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Each district in Kenya is required to determine malaria endemicity and plan and implement
an appropriate control strategy. The other factor to be considered is the objective of control
activities.

7) Treatment and Prevention of Common Diseases and Injuries

Curative care is important in its own right as it provides a powerful mechanism for teaching
preventive and promotive care.
List four of the most common conditions in your catchment area.
Check your list against the following:
• Diarrhoea diseases
• Skin diseases
• Worm infestation
• Common accidents requiring first aid; burns; wounds; bites and stings; allergic shock
• Eye conditions
• Acute respiratory infections
You can arrive at an accurate list of the common diseases in your area by reviewing the clinic or
health centre records over a period of time.

8)Supply of Essential Drugs

Essential drugs are basic drugs used to treat minor ailments or conditions at the dispensary and
health centre levels.

9)Mental Health
The WHO defined health as ‘a state of complete physical, psychological, spiritual and social
well- being and not merely absence of disease or infirmity’.
Mental health services should not be viewed in isolation but as an integral part of the other
services that are needed to achieve the complete health of individuals, families and
communities.
Health workers should therefore:
• Be oriented to look at mental health as part and parcel of PHC
• Promote good mental health practices through health education of the family and community
in order to create awareness
• Provide facilities in all health institutions and service delivery points for education, detection,
treatment or referral of mental health problems
10) Dental Health
Dental health is a strategy of care focusing on the promotive and preventive care of teeth and
the oral cavity. From your experience you are aware that dental diseases are one of the most
widespread diseases in our communities, and yet they are largely preventable. The Ministry of
Health has established fully fledged dental care units in all health facilities.
11) Community Based Rehabilitation

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Many developing countries such as Kenya included this element in order to give special
attention to the management and prevention of disabilities arising from congenital defects,
chronic non-communicable diseases such as cancers, and accidental injuries. Rehabilitation
services are now being integrated at all levels of health care delivery including at the family and
community level.
12) HIV/AIDS Prevention
The Kenyan government has set out technical and ethical approaches aimed at meeting the
challenges presented by the HIV/AIDS pandemic. These include:
• Adequate and equitable provision of health care to the growing numbers of HIV infected
people falling sick
• Treatment of other sexual transmitted diseases that increase peoples biological vulnerability
to HIV infection
• Reduction of women’s vulnerability to HIV infection by improving their health, education,
legal status and economic prospects
• A supportive socio-economic environment for HIV/AIDS prevention
The PHC approach emphasizes the need to involve individuals, family members, and community
members in the prevention and control of HIV/AIDS.
You now know the fundamentals of PHC as well as all the elements adopted by our country.
Principles of PHC
To implement the Primary Health Care elements a number of principles are involved. Although
the details vary from country to country each principle must be considered during the
implementation of PHC.
Write down the definition of the term ‘principle’.
A principle is a rule or basic belief that has a major influence on the way in which something is
done. Therefore principles of PHC are rules or guidelines that govern the implementation of
PHC activities.
There are five basic principles which govern the implementation of PHC. These are:
• Equity
• Manpower development
• Community participation
• Appropriate technology
• Multi-sectoral approach

Equitable Distribution
Equity is the fair and reasonable distribution of available resources to all individuals and
families so that they can meet their fundamental and basic needs. Services should be physically,
socially and financially accessible to everyone. People with similar needs should have equal
access to similar health services. To ensure equal access, the distribution of resources and
coverage of Primary Health Care services should be greatest in those areas with the greatest
need.
This principle should be taken into account when deciding on the location of new health
facilities, outreach services points, or during introduction of new health programmes, especially
those that require payment for services.

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Manpower Development
Primary Health Care aims at mobilizing the human potential of the entire community by making
use of available resources. This principle facilitates the identification and deployment of the
necessary health personnel as well as the training and development of new categories of health
workers to serve the community. Comprehensive PHC requires health workers to identify
solutions that involve the community, as follows:
1. It is not enough to provide oral rehydration solution and medical treatment to a sick child
with diarrhoea. Maintaining the health of the child also requires providing family education on
child care and environmental hygiene, as well as improving access to food.
2. In addition to counseling on breast feeding, growth monitoring, nutrition rehabilitation, and
child care, a nutrition program should promote weaning foods that are available locally.
3. PHC services for healthy people (prenatal care, immunization, health education) should be
established as soon as possible through community based health interventions.

Community Participation
As you learnt in unit one of this module, community participation is the process by which
individuals, families and communities assume responsibility in promoting their own health and
welfare. The PHC strategy underlines the importance of full community participation, especially
in health decision making. Community members and health providers need to work together in
partnership to seek solutions to the complex health problems facing communities today. In
addition to the health sector, families and communities need to get actively involved in taking
care of their own health. Communities should participate in the following:
• Creating and preserving a healthy environment
• Maintaining preventive and promotive health activities
• Sharing information about their needs and wants with higher authorities
• Implementing health care priorities and managing clinics and hospitals
Appropriate Technology
What do you think is appropriate technology?
Appropriate technology is the kind of technology that is scientifically or technically sound and
adaptable to local needs, and which the community can afford to maintain at every stage of
their development in the spirit of self-reliance and self-determination. It includes issues of costs
and affordability of services, type of equipment and their pattern of distribution throughout the
community. An increasing complexity in health care methods should be observed upward in the
PHC pyramid (see graphic). Care givers should be trained to deliver services using the most
appropriate and cost effective methods and equipment for their level of care.

Multi-Sectoral or Intersectoral Approach

PHC requires a coordinated effort with other health related sectors whose activities impact on
health. For example, agriculture, water and sanitation, transportation, education, etc. This is

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necessary to achieve social and economic development of a population. The health sector
should lead this effort.
The commitment of all sectors may increase if the purpose for joint action and the role of each
sector is made clear to all concerned. Lessons drawn from past experience clearly indicate that
the health sector cannot achieve much in isolation. It must work in close collaboration with
other sectors in the community in order to succeed in promoting the community’s health and
self-reliance.
Try to name four sectors which you need to work with in order to improve the health of the
community where you work.
Often, the health sector works in collaboration with
the following sectors:
• Agriculture
• Water and sanitation
• Animal husbandry
• Education
• Housing
• Public works
• Transport and communication
• Roads and housing
• Reclamation, development of arid and
semi arid wastelands
These sectors need to coordinate their plans and activities in order to contribute towards the
health of the community and avoid conflicts or duplication of efforts.

Summary
To summaries, this is what you need to remember about the principles of PHC.
• Every individual has a right to a high quality of life.
• The community must be allowed to take charge of the resources available from
both within and outside their environment. This empowers them to be more responsible and
accountable for their quality of life.
• There should be equitable distribution of resources among the community members so that
they can meet their fundamental and basic needs.

Health requires a comprehensive approach that is based on the following interventions:

Promotion and Prevention – PHC
• Promotive - addresses basic causes of ill health at the level of society. Preventive - reduces
the incidence of disease by addressing the immediate and underlying causes at the individual
level
• Curative - reduces the prevalence of disease by stopping the progression of disease among
the sick
• Rehabilitative - reduces the long term effects or complications of a health problem
Comprehensive PHC combines facility based health services (curative and rehabilitative) with
multi-sectoral public health interventions (promotive and preventive).

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Because this approach is more effective in sustaining the overall wellbeing of a population, it
should be supported by the community.

Disability act Kenya persons with disability 2003

Defination of disability:
In life, anything that stops a part of your body from functioning duly is known as impairment.
There are different types of impairment such as motor,sensory, and emotional or intellectual
impairment.
Disability is a physical, emotional, or ,mental injury or illness that is severe or permanent,that
interferes with an individual's normal growth and development or ability to work

Most disabilities start later in life or childhood. Those that at art in life are often as a result of
accidental injuries

In most cases ,the loss of a function due to disability need not make a person useless. Often
disabled people have other facilities which they can be able to put in good use and therefore be
able to earn a living for themselves.
Causes of disability:
 Chronic diseases: DM,HPT,cancer
 Injuries due to RTA,conflicts falls and land minds
 Mental health problems
 Birth defects
 Malnutrition
 HIV/AIDS
Persons with disabilities are increasingly in number due to:
 Population growth
 Increasing in chronic health condition
 Ageing
 Prolonged life
Persons with disabilities
 Need to be registered
 Not be discriminated
 Exemption from tax
 Special facilities
 Retirement 65
 Education
End

LESSON 2:
Preparation and implementation of PHC; structure of health organizations in Kenya,Government’s
Health, policy and PHC, Level of support of PHC (technical,material, manpower and organizations)

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PREPARATIONS AND IMPLEMENTATION OF PHC
Introduction
In this section, you will start by reviewing how the government implemented health care before
adopting the PHC strategy and then look at the major health policies which are currently
guiding health development in Kenya.
Lastly you will look at how the PHC elements should be implemented at the four different levels
of health care provision in Kenya.
Objectives
By the end of this section you will be able to:
• Give an overview of health services inKenya before PHC
• Look at the major health policies whichare guiding the current healthdevelopment plan
• Describe how PHC elements have beenimplementedat the following levels of health provision
in our health system: Family level; Community level; District;Provincial/National level

Health Services in Kenya Before Implementation of PHC

Since Kenya became independent in 1963, the government has all along demonstrated its
commitment towards the provision of quality health services for its people. In its various
manifestos and development plans, it has identified health as one of the basic needs and an
essential precondition for the overall economic development and social progress of this
country.

The major milestones achieved by the government in health care development are captured in
the following chronology of events. In 1965 the government introduced free medical treatment
in government medical facilities in line with the policy guidelines of the KANU manifesto.
In 1967 the national family planning programme was started.
In 1970 the central government took over the running of health services from local councils.
In 1971 - 1972, a joint GOK/WHO mission formulated the proposal for the improvement of rural
health services in the country and established six Rural Health Training Centre’s (RHTCs). This
was done in order to provide adequate health coverage to the rural population.

Try to name at least four rural health demonstration centres in Kenya.

Did you name some of the following centres?
• Karurumo rural training centre
• Chuluaimbo rural training centre
• Mbale rural training centre
• Maragua rural training centre
• Mosoriot rural training centre
• Tiwi rural training centre
In 1984 a community based health care unit was set up within the integrated rural health and
family planning project.

Indeed, the concept of community participation in development activities is not new in Kenya.
You might remember the introduction of the Harambee (self-help) movement which
encouraged people to contribute their resources and participate in the development of

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healthcare and education. People’s efforts were directed towards construction of physical
facilities like classrooms and wards with the hope that the government would take over their
management.

Similarly, community participation is an important cornerstone of the PHC strategy. The PHC
strategy relies on the abounding spirit of self-help among community members and endeavors
to empower them to improve their health.

Having seen where health services in Kenya have come from, next you will look at the direction
that health care delivery services are taking. This can be accomplished by looking at some of the
key health policies that have influenced health development.
Major Health Policies Guiding Current Health Development Plan
The steady development of PHC has necessitated a continuous review of existing policies in the
health sector.

Name at least one policy which has guided the development of PHC in Kenya.
Did you name one of the following policies?
• The district focus for rural development strategy
• Increasing coverage and accessibility of health services in rural areas
• Consolidating urban and rural curative, preventive and promotive services
• Intersectoral collaboration
You will now look at each of these policies and their effect on health services development.
The District Focus for Rural Development Strategy
This policy was introduced by the government in July 1985, to decentralize decision making to
the grass roots, and turn the district into a centre for the planning and implementation of
government projects.

As a result of this strategy, the management capabilities of health personnel at the district level
were strengthened, thus reducing many challenges which they experienced before.
Name three problems that were resolved by the introduction of the district focus strategy?
Problems that were resolved by the introduction of the district focus strategy were:
• Facilities management
• Drug supplies
• Transport
• Maintenance of equipment
The role of the District Health Management Teams (DHMT) was strengthened in line with the
district focus for rural development strategy.

Increasing Coverage and Accessibility of Health Services in Rural Areas

It was realized that development of the rural health infrastructure had lagged behind because
of financial constraints. Yet experience had shown that preventive and promotive health
programmes were more cost effective if adequately supported. So the government made a
deliberate effort to redirect capital from major capital projects to small scale projects at the
district and sub-district levels.

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Efforts were also made to support preventive and promotive health programmes, and further
investment in the rural health infrastructure, by improving service delivery methods, and
increasing the number and quality of trained health manpower.
Consolidating Urban/Rural, Curative, Preventive and Promotive Services
Here emphasis was put on training all health cadres in preventive and promotive methods.
Personnel located at hospitals and other static facilities were encouraged to include health
education as a routine component of PHC.

Intersectoral Collaboration
Intersectoral collaboration means working together with other sectors whose activities have a
direct influence on health. Health is too important to be the responsibility of the health sector
alone. Other sectors whose activities have a direct influence on health include ministries of
agriculture, water, housing, culture and social services,
and so on.
The current development plan has set out the following policies to guide health development:
• Increasing emphasis on MCH/FP services in order to reduce morbidity, mortality and fertility
rates
• Strengthening Ministry of Health management capabilities with an emphasis on the district
level
• Increasing inter-ministerial coordination
• Increasing alternative financingmechanism for health care

These major policy guidelines show the explicit direction in which health care delivery services
in Kenya have taken. For instance, there has been a clear shift from the earlier policy which
provided free medical services, to one which has introduced cost sharing. The development of
the Community Based Health Care (CBHC) approach as a basic component of PHC is another
important milestone. This approach emphasizes community participation in environmental
health activities, prevention of diseases, establishment of community health funds, and
income generating activities.

The introduction of community based health care as a strategy for achieving the goals of PHC
was a major policy step in Kenya.
The Alma Ata conference set as its target ‘Health for All by the Year 2000’. Since then the
Ministry of Health has reviewed and revised its strategies to follow the Primary Health Care
guidelines.

Through the implementation of the policies you have just covered, it has organized a number of
healthcare activities within communities according to their needs and conditions.
What kind of development activities has the community in your catchment area undertaken?
Some example activities are:
• Water project
• Kitchen gardens
• Construction of schools

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• Construction of VIP toilets
While these efforts have led to an improvement in accessibility, availability, affordability and
acceptability of health services, there are still considerable constraints and a lot more needs to
be done to completely integrate PHC.
The year 2000, which was set as the target for the achievement of health for all, came and
passed. Even five years later, health for all has not been achieved. For this target to be met, a
number of things need to change that continue to get in the way. These are:
• A change in the attitude of health personnel and the community
• A change in the motivation of both health workers and the community
• Greater intersectoral collaboration
• Political will
• Equitable redistribution of the available resource
 More appropriate and affordable health technology
LEVEL OF SUPPORT OF PHC
 Primary health care workers
 The community
 The government
 Other government ministries
 NGOs
STRUCTURE OF HEALTH ORGANIZATIONS IN KENYAN
As a health worker, you do not function in isolation. You are part and parcel of a well
designated and thorough out system that is working towards improving the health of the
nation.
The development of a country or nation is done by its people. People can only contribute and
participate in the development of their country if they are healthy.
This are of the hover is look after the health of the people.

The government carries out this activity through ministry of health and country government for
health is a devolved function

Therefore, the Ministry of health under national government is the major provider of health
function services to its citizens.
FUNCTION OF MINISTRY OF HEALTH
 Planning for delivery of health care services
 Maintaining effective health information systems
 Manpower training, recruitment and development
 Curative services
 Health care financing
 Registration and licensing of health facilities
THE HEALTH CARE SYSTEM
Kenya health sector comprises of:
 Public health system, with the major players including the MOH and parastatals, private
sectors which includes- private for profits NGO,and faith based organizations.

17
  Health services are provided through a network of over 4700 health facilities
countrywide,with the public sector system accounting for about 51% of these facilities
 Public health system levels of health facilities :National referral hospital, level 5
hospitals,sub county hospitals,health Centre’s and dispensaries.
 National referral: Kenyatta National Hospital and Moi teaching and referral hospital.
Private include aga khan and Nairobi hospital.
6

LESSON 3:
Agencies involved in PHC in Kenya,integration on of agencies and sector, level of strengthening

18
 and integration of PHC ( family,community,divisional, District)

In this section you will learn the responsibilities of the key players in the implementation of
PHC. Objectives
By the end of this section you will be able to:
Describe the responsibilities of the following key players in PHC implementation:
• Community health workers
• The community
• The government
• Other government ministries
• Non-governmental organizations

List down the key implementers of PHC in Kenya?

The following are key implementers of PHC in Kenya
 Community health workers
 The community
 The government
 Non-governmental organizations
You will now look at the responsibilities of each implementer of PHC. Community Health
Workers,Community Health Workers (CHWs), are individuals who are selected by their
communities for training on how to deal with village health problems and treat common
diseases. Once they are trained they work part- time as volunteers.

How are Community Health Workers selected?

The selection process of CHWs is usually carried out by the community after its members have
been fully sensitized on the role and advantages of CHWs, as well as their obligations towards
the CHWs. Often, several candidates are selected and interviewed by the trainers and members
of the community health committee. Those selected are required to possess the following
qualities:
 Be a permanent resident in the community.Be a mature responsible individual
 Be acceptable and respected by the-whole community
 Be self supporting and ready tovolunteer
 Be able to relate to others and a goodcommunicator
 Be physically fit
 Be of a gender acceptable to the localculture for the kind of healthactivities to be
undertaken
 Be intelligent with education/literacy thatsuits the community
 Be ready to learn
 Be of an age suitable for training and forcontinued work in the communityRoles
 A motivator through education and communication
 An example and model of good health behaviors
 A link with the health system and other sectors
 A technician with certain skills of community importance e.g. latrine construction or
basic treatment of common ailments

19
  An observer and recorder who is capable of thinking, reacting and assessing progress
 An organizer and mobiliser for community activities
 A leader and manager
 A person who is receptive to new ideas so as to form a channel through which new
health information can reach the community
 An advisor and a counsellor

The Community
You already know, the community is the centre of focus in the implementation of primary
health care. Therefore, its responsibilities include the following:
• To recognize priority problems relating to health
• Decide on what needs to be done to overcome the problems
• Decide on what the community itself can do to solve the problems
• To organize and implement whatever they themselves can do either on their own or with the
support of governmental or non-governmental agencies
• To monitor and evaluate their activities as necessary
The community meets these responsibilities through the following activities:
• Community participation
• Community awareness
• Community involvement

Community Participation
Community participation is defined as the process by which a community mobilizes its
resources, initiates and takes responsibility for its own development activities, and shares in
decision making and implementation of all other development programmes. The expected
outcome of community participation is the overall improvement of the community’s health
status.
The emphasis on community participation represents an enormous shift from former
healthcare approaches, which viewed the community as passive recipients of services planned
and provided by others.

Community Awareness
The community is made aware of its problems and the available resources, such as, manpower,
money, materials, ideas and time. Community awareness can be achieved through participation
and involvement of the community in community diagnosis (self diagnosis), and through
exposure of the community to another with successful development programmes and by
creating demand. Creating awareness is done through meetings, various groups and
development committees.
At the division level, this is done through barazas or small groups, community elders, TBAs,
churches, and women groups. In addition, health workers brief the Division Development
Committee who in turn involve NGOs and the local Member of Parliament. At location level,
PHC awareness is created by the Location Development Committee, NGO’s, politicians, and
opinion leaders. This can be done through barazas, mobile clinics, church gatherings, and
women groups.

20
Community Involvement
Community involvement entails active and willing participation of the community in planning,
management and evaluation of programmes which contribute to their well being. It can lead to
the creation of partnership between the establishment (government), other development
agencies and the community. It also contributes to the attainment of community responsibility
and accountability over all development programmes. Participation and involvement leads to
development of self reliance and helps a community to develop social control over its own
infrastructure. The level at which any community participates in its own development process
varies from place to place. A number of factors could influence the degree of community
involvement. These are:
• A favorable political atmosphere
• The educational status of the community (literacy may influence the speed at which full
participation and involvementis achieved)
• The community infrastructure (such asthe communication network)
• Economic factors

The Government
The political and economic stability of the government has significantly contributed to the
successful development of PHC in Kenya. It has provided an enabling environment for re-
orientation and change towards greatercommunity involvement and self reliance in health and
health related matters.
Responsibilities of Government at National Level
The responsibilities of the government at the national level are to:
• Ensure a consistent policy and strategy base for Primary Health Care (PHC) activities
throughout the country
• Recommend activities that should be undertaken to overcome these problems
• Avail resources to address these problems from other sectors, NGOs, and international
sources
• Ensure collaboration among the different government sectors in planning activities that have
a bearing on health. The health sector must come out of its relative isolation and collaborate
with other sectors. Health goals and criterianeed to be incorporated into policies and
programmes of other sectors Ensure the co-ordination of inputs from both bilateral and
multilateral sources in accordance with the national plan for PHC development
• The health sector needs to assist other sectors in monitoring and evaluating the health impact
of development projects. This way, negative health effects are anticipated and countered

Non-Governmental Organizations
Non-Governmental Organizations (NGOs) have been actively involved in developing Community
Based Health Care (CBHC) projects since the mid 1970’s. Although collaboration between the
Ministry of Health and NGO’s has so far been good, it could be improved even more by creation
of joint coordinating committees. Indeed, it was through such joint efforts with assistance from
WHO and UNICEF that National Guidelines for the implementation of PHC in Kenya were
formulated

21
Many NGOs have on-going CBHC schemes. Some of the NGOs actively involved in CBHC
programmes include the following:
• African Medical and Research Foundation (AMREF)
• Aga Khan Health services
• Christian Health Association of Kenya
(CHAK)
• Kenya Red Cross society
• Action Aid - Kenya
• Catholic Relief Services –b

ACHIEVEMENTS OF PRIMARY HEALTH CARE , CHALLENGES AND WAY FORWARD

In this section you will look at the achievements made in the implementation of PHC, the
challenges faced and the way forward.
Objectives
At the end of this section you will be able to:
• Give an overview of the achievements
made in the implementation PHC
• Explain the challenges met during the
implementation
of PHC
• State the way forward for PHC in Kenya
Achievements of PHC
When Kenya adopted the Alma Ata declaration of 'Health for All' by the year 2000 and beyond,
she became committed to the integration of all health programmes necessary to bring
everyone to a level of health that would permit them to lead
a socially and economically productive life.
It has been observed that it is difficult to attribute all the achievements in the health sector to
PHC interventions alone. Indeed, no attempt has been made to directly link PHC with the
changes that have been observed, because PHC is considered to be part and parcel of the
overall health care systems, and general socio- economic development of this country.
However, there has been a number of notable achievements. For example, the shift in
emphasis from curative to preventive programmes has led to a reduction in mortality and
morbidity.
Five preventive programmes were introduced through the PHC strategy, these are:
• Kenya Expanded Programme of Immunization (KEPI)
• Environmental health
• Nutrition
• Maternal child health and familyplanning
• Control of communicable and vectorborne diseases.
PHC has won widespread acceptance among government ministries, NGOs and international
agencies.
Others
 Focus on the community and use of CHEWs

22
  Hygiene and prevention of diseases like emphasis on health education and promotion of
nutrition
 Planning services as like M/E
 Organizations of service where health centers and dispensaries are within rich
 Training-CMEs

CHALLENGES
 Morbidity and mortality for easily preventable diseases are causing deaths
 Curative services are expensive
 Disease burdens like emerging and re-merging diseases
 Lack of safe water and sanitation
 Corruption

WAY FORWARD
 PROSECUTE CORRUPT PERSONS
 AVAIL WATER AND SANITATION
 PRACTICES PHC

LESSON 4:
Bamako initiative: Defination,principles and application

23
BAMAKO INITIATIVE
DEFINITION:-
The Bamako initiative was a formal statement adopted by African health minister in 1987 in
Bamako -Mali to implement strategies designed to increase the availability of essential drugs
and other care services.
Principles and application
 National commitment to the development of universally accessible essential services.
 Essential drug policies compatible with,and complementary to,the rational
development of primary health care
 Substantial decentralization to the district level of the health ministry's decision making
 Decentralized management of community resources,with funds collected at the local
facilities remaining under community control
 Community financing of health services,usually in the form of pay,net for
consultations,treatments or drugs ,which remains consistent thought out the different
levels of the health care system
 Substantial government financing support for primary health care ,preserving
and,whenever passable ,increasing the proportion of than tonal budget dedicated to
basic health services
 Measures to ensure the poorest benefits from primary health care,through fee
exemptions or subsidies,for which criteria should be established in consultation with
community.
 ] Clearly defined intermediate objectives and agreements on indicators to measure
them.
Applications
 Increase activities and rates of immunization
 Increase in antenatal utilization
 Increase In access to drugs

LESSON 5:
CBHC & Community Health Strategy: Defination,principles,strategies,role of traditional health

24
 workers-recruitment,selection,training,community participation.

COMMUNITY BASED HEALTH CARE:

Home-based care is the care of persons with chronic or terminal illnesses extended from the
hospital or health facility to the patients' homes through family participation and community
involvement within available resources and in collaboration with health care workers.

It is a holistic and comprehensive care which relies on collaboration between the hospital, the
family of the patient, and the community, in order to enhance the quality of life of the patients
and their families. In home-based care, the care of the patient is extended from thehospital or
health facility where they are initially seen to their homes.

This therefore implies that these patients require certain services. These services form the
components of home-based care.

Definition:CBHC is where people determine there own health priorities and link them with the
formal health system in order to reflect their decisions and actions in health plans.
Community strategy refers to empowering of communities to have the capacity to and
motivation to take up their essential role in health care delivery. In addition,people themselves
would participate in resources mobilization,allocation and control.
GOAL:
 To enhance community access to health care in order to improve productivity and
thus reduce poverty,hunger, and maternal deaths.
 Improve productivity and performance across all stages of the life cycle
PRINCIPLES
 Build the capacities of communities to asses,analyze,plan,implement and ,manage
health related related issues
 The community to demand their rights and accountability for they are already
empowered for efficiency and effectiveness of health and other services.
Reasons for community based approach
 Health care workers don't understand what there clients need and so they keep on
imposing and giving directives and no change takes place
 Community have the deepest interest of their own health at heart and try their best
even whatever they do look unreasonable.
 There is loss of trust by the community to health workers due to lack of listening.
 The community and providers see thing in different perspectives

STRATEGIES

25
The community strategy intends to improve the health status of Kenyan through initiation and
implementation of life cycle focused health actions.
- [ ] Providing level 1 services for all cohorts and social economic groups and take into account
their needs and priorities
- [ ] Building the capacity of the community health extension workes(CHEWs) and community
owned resource persons((CORPS)
- [ ] Strengthening health faculty community linkages through effective decentralization and
partnerships
- [ ] Strengthening the community to progressively realize their rights for accessible and quality
care and seek accountability from facility based health services
Cohorts in health care
- [ ] Pregnancy,delivery and new borns( first week of life)
- [ ] Early childhood (2 weeks to 5 years)
- [x] Late childhood ( 5 to 12 years school age
- [x] Adolescents and youth 13 to 24
- [ ] Adults persons 25 to 59 years
- [ ] Elderly persons over 60 years
Services provision at level 1 by CHEWS and CORPS
Community level activities focus on effective communication aimed at behavior
changes,disease prevention and access to basic care
This includes:-
- [ ] Disease prevention and control to reduce morbidity,disability and mortality -
HIC,Tb,STIs,malaria,epidemics.
- [ ] Family health services to expand family planning,maternal and child and youths services.
 MCH/Fp ,maternal care /obstetrics care,immunization,nutrition
 Adolescent reproductive health
 Non communicable diseases:- cardiovascular disease,diabetes anemia mental health
- [ ] Hygiene and environmental sanitation
 Personal hygiene
 Control of insects and rodents
 Food hygiene
 Excreta and solid waste disposal
Recruitment and training of corps
 Literacy in local language
 Be respected in the community and have a good heart
 Be a volunteer
 Community should participate in selecting them
Training
 Carrying out immunization ,family planning,antenatal care ,monitoring TB
 Doing health promotion and mobilizations
 Developing registers
 Educate the community on safe motherhood
 Act as a link between community and the health facilities
LEVELS OF HEALTH CARE DELIVERY IN KENYA

26
LEVEL 1:community-villages/households/families/individuals
LEVEL 2:dispensary and clinic
LEVEL 3:health center,maternities,nursing homes
Level 4: primary hospitals-sub county hospitals
Level 5:secondary hospitals like level 5
Level 6:Tertiary hospital /referral hospitals leek Kenyatta and moi.
COMMUNITY STRATEGY:

PRINCIPLES:

STRATEGIES:

ROLE OF TRADITIONAL BIRTH ATTENDANTS

Taken over by chews and corps
RECRUITMENT
Taken over by CHEWs and CORPS
SELECTION
Taken over by CHEWs and CORPs
TRAINING
Taken over by CHEWs and corps
COMMUNITY PARTICIPATION
Community participation is defined as the process by which a community mobilizes its
resources, initiates and takes responsibility for its own development activities, and shares in
decision making and implementation of all other development programmes. The expected
outcome of community participation is the overall improvement of the community’s health
status.
The emphasis on community participation represents an enormous shift from former
healthcare approaches, which viewed the community as passive recipients of services planned
and provided by others.

27
 LESSON 6: Millennium development goals:- Defination,principles and application. Sustainable
development goals, vision 2030.

MILLENNIUM DEVELOPMENT GOALS

INTRODUCTION
Millennium development goals (MDGs)are set of 8 goals which are contained in the millennium
declaration of the year 2000. Many states and Governments signed the declaration as a way to
lead to marked improvements in the new millennium. It is for that reason,therefore that the
MDGS became the world's greatest promise to the worlds most vulnerable people.

The MDGS were entrenched in Kenya in 2004 when the government of Kenya issued a cabinet
Memel directing all the ministries,agencies to mainstream MDGs in the policy, planning and
budgeting processes and procedures.

Ever since,the MDGS have been adopted into major national policy documents like the Kenya
national population policy and Kenya vision 2030.

1) Eradicate extreme poverty and hunger

 Prevalence of underweight children under 5 years of age
2) Achieve universal primary education
 Net attendance ratio in primary education1 2.3 Literacy rate of 15-24 year-
olds2
3) Promote gender equality and empower women
 Ratio of girls to boys in primary, secondary and tertiary education 3.1a
Ratioofgirlstoboysinprimaryeducation3
 Ratioofgirlstoboysinsecondaryeducation3
 Ratioofgirlstoboysintertiaryeducation3
4) Reduce child mortality
 Under five mortality rate4
 Infant mortality rate4
 Percentage of 1 year old children immunized against measles
5) Improve maternal health
 Maternal mortality ratio
 Percentage of births attended by skilled health personnel6
 Contraceptive prevalence rate7
 Adolescent birth rate
 Antenatal care coverage
 At least one visit
 Four or more visits
 Unmet need for family planning
6) Combat HIV/AIDS, malaria and other diseases
 Condom use at last higher-risk sex

28
  Percentage of the population age 15-24 years with comprehensive correct
knowledge of HIV/AIDS
 Ratio of school attendance of orphans to school attendance of non-orphans age
10-14 years
 Percentage of children under 5 sleeping under insecticide-treated bed nets
 Percentage of children under 5 with fever who are treated with appropriate
antimalarial drugs
7. Ensure environmental sustainability
 Percentage of population using an improved water source15
 Percentage of population using an improved sanitation facility

Millennium Development Goals for 2015Indicators

Goal 1: Eradicate extreme poverty and hunger • Prevalence of underweight children under 5
years of age
Goal 2: Achieve universal primary education • Net attendance ratio in primary education
• Literacy rate of 15-24 year olds
Goal 3: Promote gender equality and women’s • Ratio of girls to boys in primary, secondary, and
empowerment tertiary education.
Goal 4: Reduce child mortality • Under-five mortality rate
• Infant mortality rate
.Proportion of 1 year-old children immunized
against measles
Goal 5: Improve maternal health • Adolescent birth rate
• Contraceptive prevalence rate
• Antenatal care coverage
Goal 6: Combat HIV/AIDS, malaria, and other
diseases • Condom use at last high-risk sex
• Population age 15-24 with comprehensive
knowledge of HIV
• Ratio of school attendance of orphans to school
attendance of
non-orphans age 10-14
• Births attended by skilled health professional
• Population using an improved water source
Goal 7: Ensure environmental sustainability • Population using an improved sanitation facility

Goal 8: Develop a global partnership for Not applicable to 2014 KDHS

development

SUSTAINABLE DEVELOPMENT GOALS

29
Voices round the world are demanding leadership on poverty,inequality and climate change. To
turn these demands into action,world leaders gathered on 25/09/2015 at the United Nations in
New York to adopt the 2030 agenda for sustainable development.
The 2030 agendas comprises 17 new sustainable Development goals (SDGs) which will guide
policy's and funding for the next 15 years beginning with the historic pledge to end
poverty ,everywhere permanently.

GOAL 1:END POVERTY IN ALL ITS FORMS EVERYWHERE

Eradicating poverty in all forms remains one of the greatest chAlleges facing humanity. While
the number of People living in extreme poverty has dropped by more than half-from 1.9 billion
in 1990,to 836 million in 2015-too many are still struggling for the most basic human needs.

Globally,many people are living in abject poverty,less than a dollar per day.
There is lack of adequate food,clean drinking water and sanitation. Women are
disproportionately more likely to live in poverty than men due to unequal access top paid
work,education and property.

The sustainable development goals (SDGs) are a bold committed to finish what we started,and
end poverty in all forms and dimensions by 2030. This involves targeting those living in
vulnerable situation,increasing access to basic resources and services,and supporting
communities affected by conflict and climate-related disaster.
GOAL 2: ZERO HUNGER
Rapid economic growth and increased agricultural productivity over the past two decades has
seen the proportion of undernourished people drop by almost half.
Many developing countries that used to suffer from famine and hunger can now meet the
nutritional needs most vulnerable.

These are all significant achievements in reaching the targets set out by the first Millennium
Development Goals. Unfortunately,extreme hunger and malnutrition remain a huge barriers to
development in many in many countries.795 million people are estimated tone chronically
undernourished as of 2015,often as a direct consequences of environmental
degradation,drought and loss of biodiversity.

The sustainable development goals aim to end all forms of hunger and malnutrition by
2030,making sure all people-especially children and more vulnerable-have access to sufficient
and nutritious food all round. This involves promoting sustainable agriculture practices:
improving the livelihood and capacities of small farmers,allowing equal access to
land,technology and markets.
GOAL 3:GOOD HEALTH AND WELL-BEING
Since the creation of MDGS,there has been historic achievement in reducing child
mortality,improving maternal health and tackling HIV/AIDs,tuberculosis,malaria and other
diseases. In 15 years,the number of people newly affected by HIV each year has dropped
from3.1 million to 2 million and over 6.5 million were saved from malaria as well as a fall on
maternity deaths

30
Nevertheless,many AIDS is a leading killer and despite this progress,many people are dying due
to HIV/AIDS related illness and are not accessing antiretroviral therapy. Also,chronic diseases
are pushing households from poverty to deprivation. Noncommunicable diseases like
cancer,diabetes and and cardiovascular diseases impose a large burden to health. Goal 3
ensures health and wellbeing for all including a bold commitment to end the epidemic of AIDS
TB,Malaria and other communicable diseases by 2030. It also aims to achieve universal health
coverage,and provide access to safe and effective medicines and vaccines for all.
GOAL 4: QUALITY EDUCATION
Since 2000,there has been enormous progress in achieving the target of universal primary
education. The total enrollment rate In developing regions reached 91% in 2015, and the
worldwide number of children out of school has dropped by almost half.
There has been a dramatic increase in literacy levels and many more girls are in school than
never before. This are all remarkable progress. However,progress has been tough especially in
developing countries due to high levels of poverty,armed conflicts and other emergencies.
Achieving inclusive and quality education for all reaffirms the belief that education is one of the
most powerful and proven vehicles for sustainable development.
GOAL 5:GENDER EQUALITY
Providing women and girls with equal access to education,health care ,decent work and
representation in political and economic decision making
GOAL 6: CLEAN WATER AND SANITATION
Water scarcity affects more than 40% of people around the world,and alarming figure that is
projected to increase with the rise of global temperatures as a consequence of climate change.
More than 2.1 billion people have gained access to improved waters sanitation since
1990,there has been dwindling supplies of safe drinking water which is impacting every
continent.
There is increased desertification and drought which exacerbating his problem of water
scarcity.
It is for that reason therefore that ensuring access to safe and affordable drinking water by
2030 requires we invest in adequate infrastructure,provide sanitation facilities and encourage
hygiene at every level. Protecting and restoring water related ecosystems such as forests
mountains,wetlands and rivers is essential if we are to meting ate water scarcity.
GOAL 7:AFFORDABLE CLEAN ENERGY
Between 1990 to 2010, the number of people with access to electricity has increased by 1.7
billion,and as the global population continues to rise so will be the demand for cheap energy. A
global economy which relies on fossil fuels and the increase of greenhouse gas emissions
creates drastic changes to our climate.
There has been a new drive to encourage alternative use of Renewable energy sources such as
wind,solar,and thermal
GOAL 8: DECENT WORK AND ECONOMIC GROWTH
Over the past 25 years the number of workers living in extreme poverty has declined
dramatically,despite the long lasting impact of economic crisis of 2008/09. However as the
global economy continues to recover,we are seeing slower growth,widening inequalities and
employment that is not expanding fast enough to keep up with the growing labour forces.

31
The sustainable goals aim to encourage high productivity and technology innovation. It also
wants

GOAL 9: BULD RESILIENT INFRASTRUCTURE,PROMOTE SUSTAINABLE INDUSTRIALIZATION

AND FASTER INNOVATION
Sustainable investment in infrastructure and innovation are crucial drivers of economic growth
and development. Half of the world population lives in cities and so mass transport and
renewable energy are becoming ever important. There is also need for growth of new
industries,information transfers and communication technology hence the importance to invest
in scientific research.
GOAL 10: REDUCE INEQUALITIES
It is well documented that income inequality is on the rise with 10% of the population earnings
40% of the global income. This is so apparent in Kenya where the income earnings for top brass
of the civil servants ear more as compared to the junior servants who do the donkey of the
work. There is as well the gap between the rich and the poor which is widening every unfolding
day. It for that reason Kenya has set up the remuneration commission which desires to adjust
the remuneration accordingly.
GOAL 11: SUSTAINABLE CITIES AND COMMUNITIES
This is to make cities, inclusive,safe resilient and sustainable. More than half of the population
live in urban areas. By 2050,that figure shall rise to 6.5 billion hence 2/3rd of the human
population.
Sustainable development can't be achieved without significantly transforming the way we build
and manage our urban spaces. The rapid growth of towns coupled with increasing rural urban
migration has led to a boom in mega cities. In the city,there is extreme poverty and the cities
struggle to accommodate the ever increasing population.
Making cities safe and sustainable means ensuring access to safe and affordable housing,and a
upgrading slum settlement. It also involves investment in public transport,creating green public
places and improving urban planning and management in WA way that is both participatory
and inclusive.
GOAl 12: RESPONSIBLE CONSUMPTION,PRODUCTION
To achieve economic growth and sustainable development it requires that we urgently reduce
our ecological footprint by changing the way we produce and consume goods and resources. A
lot of water is used by agriculture and irrigation.
It is important to manage natural resources efficiently and dispose toxic substances in proper
manner. We should as well encourage consumers,businesses and industries to recycle and
reduce waste productions.
GOAL 13: CLIMATE ACTION
There is no country in the world which is not seeing the first hand the drastic effect of climate
change. There is effect of green house rise,with subsequent global warming which cause long
lasting impacts on the climate systems and has got irreversible consequences if action is not
taken now.
It has led to earthquakes,tsunami,drought etc.
GOAL 14: LIFE BELOW WATER

32
The world oceans-temperatures,chemistry,currents and life drive global systems that make the
earth habitable for human kind. Many people depend on coastal regions for there livelihoods.
But the fish stock is diminishing so quickly due to exploitation and over fishing.
Oceans absorb over 30% carbon dioxide produced by humans and we the acidification in the
sea is raising due to industrial toxicity which get discharged into the ocean
Sustainable development goals create a framework to sustainably manage and protect marine
and costal ecosystem from land based pollution as well as addressing the impacts of ocean
acidification.
GOAL 15: LIFE ON LAND
Human life depends on earth as much as the ocean for our sustenance and livelihoods. 80% of
human diet come from plants and we rely on agriculture as an important economic resource
and means of development. Forests accounts for over 30% of earths surface hence providing
vital habitats for species and important source of clean air and also are crucial for combating
climate change.
Today we are seeing unprecedented land degradation, and loss of arable land .There is rise of
drought and desertification hence loss and extinct of some plants and animals.
It is for that reason therefore that sustainable development goals aim to conserve and restore
the use of terrestrial ecosystem such as forests,wetlands,dry land and mountains by 2020.
Promoting the sustainable management of forests and halting deforestation is also vital to
mitigating climatic change.
GOAL 16: PEACE,JUSTICE AND STRONG INSTITUTIONS
The sustainable development goals aims at significantly reduce all forms of violence and work
within government and communities to find lasting solutions to conflict and insecurity.
GOAL 17: PARTNERSHIP FOR THE GOALS

VISION 2030-KENYA
Kenya vision 2030 is the country's new developments blue print covering the period 2008 to
2030. It aims to transform Kenya into a newly industrializing," middle-income country providing
a high quality life to all citizens by the year 2030"
Development of the vision:
 Was through consultative forum involving all citizens -through workshops with all stake
holders in public and private sectors,civil society,the media, and NGOs.
 Suggestions from leading and international experts-researchers,
The vision is based on three pillars
1. Economic : TO maintain a sustained economic growth of 10% p.a over next 25 years.
2. Social: a just and cohesive society enjoying equitable social development in a clean and
secure environment
3. Political: TO realize a democratic political system founded on issue-based politics that
respects the rule of law,and protects the rights and freedoms of every individual in Kenya
society.
1.ECONOMIC PILLAR:

33
  Macroeconomics stability for long term development .
 Continuity in government reforms:-anti corruption programs,better investigations,public
education and judicial reforms.
 Enhanced equity and wealth creation opportunities for the poor:-investment in ASALS,
youth employment women and all vulnerable groups.
 Infrastructure:-railway's ports,water and sanitation facilities and telecommunication.
 Energy:-encouraging more sources of energy sources and commenting Kenya to energy-
surplus .
 Science,technology and innovation:-research and development so as to accelerating
economic development in all new industrialized areas.
 Land reforms:-respect for property rights,whether owned by individual,communities or
companies. Adhering to land use policy by facilitating land computerization,land
administration and issuance of tittle deeds.
 Human resources development:-establishment of human resources data base and also
raising labour productivity to international standards.
 Security:-The vision for security is "a society free from danger and fear".
 Public service:- an efficient motivated and well trained public service.there is also a
need to bring an attitudinal in public service that values transparency and accountability
to the citizens of Kenya.

For Kenya to achieve vision 2030, there are six economic drivers aimed at making Kenya a
success. This are:
- Tourism
- Increasing value in agriculture
- A better and more inclusive wholesale and retail trade
- Manufacturing for the regional markets
- Business process offshoring
- Financial services
SOCIAL PILLAR
Kenya's journey towards prosperity also involves the building of a just and cohesive society that
enjoys equitable social development in a clean and secure environment. This quest is the basis
of transformation of our society in seven key sectors.this are:
 Education and training:- fund research,reduce illiteracy levels, increase enrollment of
students in public and private universities.
 Healthy sector:- TO improve the overall livelihoods of Kenyan,the country's aims to
provide an efficient and high quality health care system with best standards. This will be
done thorough a two prolonged approach.
1).Devolution of funds and management of healthy the communities; living the ministry to deal
with policies and research.
2).Shifting the bias of the national health bill from curative to preventive care
Special attention will be paid to lowering the incidences of HIV/AIDS, Malaria and TB and
lowering infant mortality ratio.

34
All this will reduce equalities in access to health care and improve key Areas where Kenya is
lagging behind especially lowering mortality and infant mortality. Specific strategies will involve:
- Provisions of robust health infrastructure network
- Improving the quality of health services delivery to the highest standards
- Promotion of partnerships with the private sectors
- Provisions of waiver
- Become health tourism destination
 Water and sanitation:-conserve water sources and start be ways of harvesting and using
rain and underground water.
 Environment:- increase forests cover,and decrease environmental diseases, improving
pollution and waste disposal
 Housing and urbanization:-planning for decent and high quality Housings
 Gender,youth and vulnerable groups
 Equity and poverty elimination

POLITICAL PILLAR
The political pillar envisions a countywide with a democratic system reflecting the aspirations
and expectations of its people. Kenya will be a state in which equality is entrenched,irrespective
of ones race, ethnicity,religion ,gender or social Economic status; a nation that not only
respects but also harnesses the diversity of its people values,aspirations and traditions for the
benefit of its people.
* Rule of law:- increase service availability and access to justice.
* Electoral and political process
* Democracy and public service delivery
* Transparency and accountability
* Security,peace-building and conflict management

LESSON 7:

35
 Health education:Defination,principles of health education;models of good education;Teaching
methods in health education

HEALTH EDUCATION
Objectives:-
- Participate in provision of health education to the community.
- Participate in provision of health care to the community
CONTENT
Definition of CBHC; Definition of health education; principles of Health education; Models of
health education; Teaching methods in health education; Characteristics of health of good
communication;Barriers of communication;Use of teaching aids in Health education; Role of
community health workers in Health education; Social/ community mobilization

Before discussing health education,it is important to know what health means. Health is highly
a subjective concept. Good health means different things to different people. Many people
consider themselves health if they are free of disease or disability. However,people who have a
disease or disability consider themselves health if they are able to manage the condition.
WHO defines health as state Of complete physical,mental,and social well being and not mere
absence of disease or infirmity.
 Physical health :-refers to anatomical integrity and physiological functioning of the bod
 Mental health is being able to learn and think clearly
 Social health is the ability not make and maintain acceptable interactions with other
people
 Disease is the existence of some pathology or abnormality
Historical development of health education
Health education is not new. In African traditional societies,people knew poisonous plants and
animals bans so he educated the rest of the people in the same.
Health promotion received a big boost at the Alma Ata international conference on primary
health care 1978. Primary health care was identified as an approach that would ensure health
services are accessible,acceptable,affordable and available to all people of the world.
The Alma Ata declaration identified various key elements for PHC implementation with health
education ranked as the most important approach for effective health promotion,and disease
prevention and thus Kenya government is utilizing the same.

Definition:-
CBHC is for people of all ages who need health care assistance at home. Health education Is a
social science that draws from the biological,environmental,psychological,physical and medical
sciences to promote health and prevent disease,disability and premature death through
education driven voluntary behavior change activities.

36
HEALTH EDUCATOR
At the heart of health education is a health educator. Is a professionally prepared individual
who serves in a variety of roles and is specifically trained to use appropriate educational
strategies and methods to facilitate the development of policies,procedures,intervention and
systems conducive to the health of individuals,groups and communities.
Importance of health education
 Health education improves the health status of individual,families,communities,states
and the whole world
 Health education enhances the quality of life for all people
 Health education reduces premature deaths
 By focusing on prevention,health education reduces the costs ( both financial and
human) that individuals,employers,families,insurance companies,medical facilities,the
star and the nation would spend on medical treatment.
AIMS OF HEALTH EDUCATION
 Motivating people so as to adopt healthy- promoting behaviors by providing appropriate
knowledge and helping to develop positive attitude.
 Helping people to make decisions about their health and acquire the necessary
confidence and skills to put their decisions into practice
Goals of health education
1. Improvement of health:- Health educators help people improve their health in all stages of
life. Educators work in a wide variety of settings and for a wide variety of age groups.eg.some
educators visit schools to speak to students about basic aspects of health like hand washing and
drug abuse.
2. Improvements in decision making:- Health educators help people make better health
decisions. To do so,they often tailor their messages to the group they a educating. E.g. Health
educators and college girls on the use of contraceptives. They may also explain the risks of
unhealthy habits like smoking,drug abuse etc.
3. Fighting diseases:-- A goal of health educator is to minimize the occurrence of life
threatening illness like DM,HPT
4. Fighting misconception:- There are misconception that affect people's health like use of
artificial sweeteners which people think are health but some are so toxic.
5. Provide resources :Health educators often distribute educational resources in the form of
packets,fliers and pamphlets.

Principles of health education.

 ] All healthy education should be need based. Therefore before involving group or the
community in health education with a particular purpose or for a program the need
should be ascertained. It has to be specific and relevant to the problems and available
solutions.

37
  Health education aims in change of behavior. Therefore multidisciplinary approach is
necessary for understanding of human behavior as well as for effective teaching
process.
 It is necessary to have a free flow of communication. The two way communication is
particularly important in health education to help in getting proper feedback and get
doubt cleared.
 The health educator has to adjust his talk and actions to suit the group for whom he has
to give health education.eg.when the health educator has to deal with illiterate and
poor people,he has to get down to their level of conversation and human relationships
so as to reduce any social distance.
 Health education should provide an opportunity for the clients to go through the stages
of identification of problems,planning,implementation and evaluation. This is of special
importance in the health education of the community where identification of
problems,implementing and evaluation are to be done with full involvement of the
community to make it the community's own program.
 Health education is based on scientific findings and current knowledge. Therefore a
health educator should have recent scientific knowledge to provide health education.
 The health educators must make themselves acceptable. They should realize that they
are enablers and not teachers. They must win the confidence in of clients.
 The health educators should not only have correct information wth the on all matters
they have to discussion but also should themselves practice what they profess.
Otherwise they will not enjoy.
 It must be remembered that people are not absolutely without information or ideas.
The health educators are not merely passing information but also give an opportunity
for the clients to analyze fresh ideas with old ideas,compare with past experiences and
take decisions that are found favorable and beneficial.
 The health educators should use terms that can be immediately understood.Highly
scientific jargon should be avoided.
 Health education should be done step by step.

MODELS OF HEALTH EDUCATION

 The persuasion approach:- This is deliberate attribute to to influence the other persons
to do what we want them to do[directive approach]
 The informed decision making approach:- where you give people information,problem
solving and decision making skills but you the actual choice to the people.
Target groups in health education
The target population for an education intervention is made up of several groups. In order to
adopt the approaches to each group, it is necessary to differentiate between these groups.
vulnerable groups and Target groups
It is important to differentiate between target groups for intervention. The vulnerable group
may in fact be the same as a target group of communication in a health education programs but
this is rarely the case.This include:-
 Individual such as clients of service,patients,health individual

38
  Groups such as students or youth club
 Community e.g. People in a village..
These targets can be distributed as:-
 Primary target:- is composed of persons whose behavior is to be modified. By
modifying their behavior,the desired effect is likely to be achieved if not
guaranteed! In the example above,these persons could well be the mother of
children under five years. In that case the aim would be to modify the manner in
which they prepare their children's meals or care. Primary target may include
mothers,adolescent, university students etc
 Secondary target:- is made up of people who will be used as R to get the message
across to the first target. In same example,it could be fathers,health
workers,teachers,agricultural promoters or journalists.
 Tertiary target:- is a group made up of people who can facilitate the
communication process and behavior change. They include administrators and
politicians but also these persons close to the mother- father of The child and
extended family.
This implies that the approach will vary for segments differing in terms of educational
level,social- economic status etc.

39
 LESSON 8:
Characteristics of good communication;Barriers of good communication,use of teaching aids in
health education;Role of community health workers in health education, social/Community
mobilization

CHARACTERISTICS OF GOOD COMMUNICATIONS

What is communication? Is the process of sharing of ideas,information,knowledge,and
experience among people to take action. Communication may take place between one person
and another,between an individual and a group or between two groups.
Reasons for communication
 To have dialogue with communities
 Influence decisions makers to adopt health promoting policies and law
 Raise awareness among decision makers on issues regarding poverty,human
rights,equity,and environmental issues.
 Communicate new laws and policies to the public
 Develop community action on health issues
Types of communication
1. One - way communication:- This is a linear type of communication in which information
flows from the source to the receiver. There is no input (feedback) from the receiver.
Sender➡️message➡️channel➡️receiver
2. Two way communication :- As the message is more complex,two- way communication
becomes essential. In this type of communication,information flows from source to the receiver
and back from the receiver to the source. The addition of feed back allows the sender to find
out how the message is being received and so it can be monitored and adopted to better Sui
the receivers need.
Sender ➡️message➡️channel ➡️receiver↩️
Feed back
Health messages
Health messages are passed from the source to the audience through processing of
communication. As said above,Communication is the process by which a message is transmitted
from a source to a receiver in order to obtain mutual understandings.

There are different ways to communicate.For example,a message can be communicated

verbally,in writing,or through facial and eye expression. The way we communicate will depend
on the mood we are in or the mood of the receiver.
Nevertheless,whatever the situation,we must communicate effectively if we want to be
understood.

Effective communication is a two way process whereby a message is initiated by one person or
persons and sent through an appropriate channel to a targeted receiver. This form of
communication can sometimes bring about change. We know that our communication has

40
been effective if there is feed back from the receivers in the the form of a response or action.
The process requires both information and understanding.

COMPONENTS OF COMMUNICATION
Four major elements contributes to effective communication. These include the sender,the
message, the channel and the receiver.
1. SENDER:- The sender (communicator) initiates the communication process. A health worker
conducting health education is often the initiator/ communicators of the message. A good
communicator should have the following qualities:-
 Know the "knowledge" level of the receiver i.e. You should know who your receiver is
and how much he or she knows about the subject already. This way your message can
be at the level of your target audiences.
 Be good listener. This is a useful skill,especially if you are to involve the receiver in
solving a problem.
 Try to feel and see things as the receiver sees and feels (empathy). This does not mean
that you always agree,but you must try to understand each other.
 Know the subject well or at least know where the receiver can get more information.
 Respect the culture an beliefs of the receivers. For example, dress in a way the people
you address expect you dress.
 Use a language the receiver understands.
 Talk with the audience/ receiver. Do not simply talk to them. Health education involves
correct information,right perceptions and adoption of desired actions. Therefore there
should be room for questions and discussion.

2. The message
The message should be relevant to the receiver. If the people receiving the message think it has
nothing to do with them,they will ignore it. The message should also be interesting. In
addition:-
 The message should hold the receiver's attention .
 It should be simple and clear. Use the language the receivers understands.
 A health message should communicate a benefit. Many of our messages appear as
commands. For example: " DO not smoke""immunize your child". This kind of message
does not offer an opportunity for the receiver to understand the reasons underlying the
message. A better message would be something like " An immunized baby is healthy
and strong.Ensure that your child is fully immunized against the childhood six diseases.
3. The channel
A channel is the medium of a way in which message are delivered to the intended receivers. In
some parts of the country's,it may seem modern to telecast health messages on television,but
if the intended audience has no access to television sets,your affords are in vain. Also if many of
the targeted receivers cannot read, then posters with clear pictures will work better than
posters with information in printed words.

41
The choice of a channel may depend on the message being passed on. For instance, if the
message involves teaching a skill, then you should use the channel that gives you a chance to
demonstrate the skill.

In nutrition education,for example,showing food items rich in different nutrients and how to
prepare these foods to minimize the loss of nutrients and maintain food hygiene would be
appropriate.

It is important to note that you can use more than one channel to communicate a single
message. The same message can be channeled through health talks in outpatient
department,one-on-one communication with patients,posters,by radio and through influential
people- all at the same time.
In other words,the message can be received by any of the five senses such as
hearing,seeing,touching,smelling and tastings.
4. The receiver:-
Also known as the target audience and refers to the person or a group of people to whom a
communicator intends to send a health education message.
Receiver can be classified as:
- [x] Primary target :- is the person upon whom change is intended. For example,your primary
target audience may be schoolchildren whom you want to educate on how to brush their teeth
every day,comb their hair, and Nate,because basic hygiene promotes good health
- [x] Secondary target:-is the person who assist in influencing the primary target. In this case the
secondary targets are the parents,guardians and teachers. This are the people you can
influence to act positively in helping the primary targets.

METHODS OF COMMUNICATION
- [x] INTRAPERSONAL:-it takes place inside a person
- [x] Interpersonal:- interaction between two or more people's
- [x] Mass communication:- means transmitting messages to a large audience that usually
reaches a large segment of the population. It uses mass media:- radio,and
television,newspapers,books, leaflets and posters.
BARRIERS TO EFFECTIVE COMMUNICATION
A breakdown can occur at any point in the communication process. Barriers or obstacle can
inhibit communication resulting to misunderstanding,lack of response or motivation. They
include:-
 Competition for attention like noise
 Language differences
 Age difference
 Attitude and believe

Skills to use when communicating

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 i. Present the message clearly and simple:-This involves using words that are familiar
to the audience. Find local names for common diseases. It is important to keep the
presentation short ,since Long session bore listeners.
ii. Listen effectively:- listening is a way of showing respect to your health audiences.
Listening is important because it allows the communicators to learn how the
receivers feels about a problem and the reasons for the actions being taken. When
listening,give the other person your attention so you understand what you are
being told. Do not make yourself busy with work or something else while the other
person is talking to you. This will hinder communication.
iii. Ask questions:- Asking questions makes communication between people more
accurate. It can help to clarify what someone has said. After listening,restate what
was said in your words. Then confirm that you heard correctly by asking the other
person. This kind of interaction leads to good communication. You can also use
question to check whether your receiver has received the message.
iv. Use interactive discussion:- in discussions,both the sender and the receiver
participate in the communication. By applying good listening skills and asking
questions the health worker encourages the receivers to participate actively in the
communication.
v. Use pictures and illustrations that are familiar the the receiver:- sometimes,images
are enlarged to make them clearer for the receiver.

USE OF TEACHING AIDS IN HEALTH EDUCATION

AUDIOS:- include anything such as spoken word,music or any other sound. There are selected
teaching aids like
* Health talk
* Visual aid
Non- projected materials (AIDS) or graphics.
* Leaflets
* Newspapers
* Photographs
* Posters
* Flip charts
* Displays
Projectedaids
* Mass media- radio,tv,microphone newsprint posters and exhibition

WHO IS RESPONSIBLE FOR HEALTH EDUCATION

Health education is duty of everyone engaged in health and community development activities.
Health extension workers (CHEWs,CORPs) are primarily responsible in working with the families
and community at grass level to promote health and prevent disease through provision of

43
health education. If health workers are not practicing health education,they are not doing their
job correctly. When treating someone with skin infections or malaria, a health worker should
educate the patient about the cause of the illness and teach preventive skills. Drugs alone will
not solve the problems. Without health education,the patient may fall sick again from the same
disease.
Role of community health workers in health education
- [x] Talking to the people and listening to them.
- [x] Thinking of the behavior or action that could cause ,cure and prevent these problems.
- [x] Finding reasons for people behavior
- [x] Helping people to see the reasons for their actions and health problems
- [x] Asking people to give out their own ideas so as to solve a problem

SOCIAL/ COMMUNITY MOBILIZATIONS

MOBILIZATION STRATEGIES FOR COMMUNITY PARTICIPATION AND INVOLVEMENT
Before ,the health workers underrated the level of intelligence of the health services
consumers. This was wrong approach to health services provisions which led to non- utilization
of or under utilization of many governments health centers and hospitals. Today,the health
workers see the community people who are consumers of health services as partners in
progress and active participants in health care planning and provision for service.
STEPS TAKEN BY A HEALTH WORKER TO ENSURE COMMUNITY
PARTICIPATION AND INVOLVEMENT
1. Introduce yourself to the head of the community on the 1st visit. This is a courtesy call. This
helps to create rapport with community and reduce the level of suspicion of the people about
your identity.
2. Carry out community diagnosis if it had not been done. If it had been done, read the
recommendations.this will help to answer many questions such as:-
 Demographic characteristics of the community
 The felt and unfelt needs of the community
 Major causes of deaths for children and adults
 Channel of communication
 Taboos and cultural practices
3. Discuss the findings of community diagnosis with representatives of the community
4. Lease with the community leaders for the purpose of setting up a community development
health committee.
5. Mobilize all the available resources to achieve the PHC
6. Community health workers should be selected for training by the community.

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 LESSON 9:
Immunization:National immunization schedule,:-principles,Goals,Objectives ;Immunizable
diseases,vaccines-types and administration

IMMUNIZATION
Introduction:
The immunization program is a global programme for the control of vaccine preventable
diseases among children and people of all ages. In the Global Vaccine Plan(GVP), there is a set
ambitious plan goal of eradicating and certification of a poliomyelitis free world by 2018,by
2020 measles and rubella.

In Kenya Expanded Programme on Immunization (EPI) was launched in 1980'with the main of
providing immunization against six killer diseases of childhood,namely
 Tuberculosis
 Polio
 Diphtheria
 Whooping cough,
 Tetanus
 Measles to all children in the country before their first birthday,and tetanus toxoid
vaccination to all pregnant women. EPI has introduced variety against hepatitis B virus
and haemophilus influenza type b bacteria.

IMMUNITY
Is the ability of the human body to tolerate the presence of materials indigenous to the body
(self), and to eliminate foreign materials. This des criminally ability provides protection from
infectious disease, since most microbes are identified as foreign by the immune system.
Immunity to microbe is usually indicated by the presence of antibody to that organism.
Immunity is generally specific to a particular organism or group to closely related organisms.
HISTORY OF IMMUNIZATION
Over 200 years ago,Edward Jenner first demonstrated that vaccination offers protection
against small pox,by cutting an arm of a boy(James Phipps) and placing the materials from cow
pox(mild disease) into the wound. Later,he injected the boy with fluid from small pox and the
boy did not contract the small pox disease. This experiment led to the inoculation of persons wi
h relatively harmless disease materials which could protect them from a more dangerous
disease. This was called vaccination ("vacation" is Latin word for cow". Since then,the use of
vaccine has continued to reduce the burden of many bacterial and viral diseases. Small pox has
been eradicated,and poliomyelitis no longer occurs in many regions of the world as a result of
widespread effective vaccination.

Natural History of infection

45
The first phase in the natural history of an infection is the progression from a healthy state to
disease state. This is marked by the entry and multiplication of infectious agent in the host. So,
the patient remains in sub clinical state until,signs and symptoms appear.
In the second phase, there's interaction between the pathogens or pathogens toxins and the
body which result into disease. There is marked appearance f signs and symptoms of try
disease. The interval between the exposure to an infectious agents and onset of clinical disease
is called the incubation period.
The third phase is the outcome of the infection which depends on how the body handles the
pathogen to or the toxin. This phase is marked by either a full recovery,recovery with disability
or death.

THE CAUSE OF INFECTION

Infection are cause by organisms which get into the body through inhalation,ingestion,or
penetration of the skin/mucus membrane. These organisms multiply in the body tissues/blood
and cause illness. Disease causing organisms include : bacteria,viruses,parasites and fungi.
Some microorganism produce chemicals called toxins which cause illness.

HOW THE BODY DEVELOPS IMMUNITY

There are two basic ways to acquire immunity against infections-active immunity and passive
immunity
A. Active immunity :- When a person's own immune system is stimulated to produce
antigen specific antibodies and immune cells. This type of immunity often lasts for many
years and it may be permanent. Active immunity can be divided into :

 Natural active immunity -This is the immunity acquired after an individual has survived
an infection with the disease causing form of the organisms. When a foreign particle or
organism invade the body, white blood cells called lymphocytes identify the
substance,also referred to as the antigen. The white blood cells produce
antibodies,which when they are in sufficient quantities,are able to identify the antigens
and kill the them or inactivate them. This means next time the the same organism
attacks the patient ,the lymphocytes are ready to produce large amount of
antibodies,which will overcome the organisms. The patient will not get ill again hence
he/ she is said to have acquired natural immunity.

 Artificial active immunity : This type of immunization is given through vaccine

administration. A vaccine is made from an organism which is either killed or
attenuated,that means it has lost its harmless,or its part or toxin rendered harmless
("toxoid").e.g oral polio makes the child to produce antibodies against polio virus and
hence will protect the child against poliomyelitis without the child falling sick.

46
 B. Passive immunity:-results when antibodies are transferred from one person
to another. Passive immunity disappears over time and usually within weeks or months.
It is divided into:
 Natural passive immunity:-Passively acquired antibodies are responsible for the
protection of newborn and young infants against certain diseases. The transfers of
antibodies from mother to fetus across the placenta during the last 2-3 months of
pregnancy provides the newborn with a portion of the mother's immunological
experience. Examples include:
o Tetanus antibodies induced in the mother following immunization with
tetanus toxoid easily passes across the placenta to the unborn child
providing protection against tetanus in the neonatal period.
o Measles antibodies made by the mother passes through the placenta and
the breast milk protecting the newborn during the first months of life.
 Artificial passive immunity:- This means the antibodies have been borrowed and
they are prepared from serum of person or animals that have been exposed to an
antigen and has produced antibodies which are purified and are directly injected to
the person at the site of infection to immediately counteract the offending antigen
HERD IMMUNITY
May be defined as the resistance of a group to an attack by a disease to which a large
proportion of the members of a group are immune to.
If a large percentage of the population is immune,the entire population is likely to be protected
and not just those immune.
Why does herd immunity occur? It happens because disease spreads from one person to
another in any community. Once we reach a certain proportion of people who are immune in
that community,the likelihood is smaller that an infected person will encounter a susceptible
person to who he can transmit the infection for more of his encounters will be people who are
immune.

Also,the presence of large number of immune people in the population lessens the likelihood
that a person with disease will come onto contacts with a susceptible individual.

Why is the concept of herd immunity so important? Because when we carry out immunization
programs it may not be necessary to achieve 100% immunization rates so as to immunize the
population successfully.

We can achieve highly effective protection by immunizing a large part of the population for the
remaining part will be protected because of herd immunity.

TYPES OF VACCINES USED IN KENYA

a)Live attenuated:- Are derived from disease causing viruses or bacteria that have been
weakened under laboratory conditions. They will multiply Ina a vaccinated individual,but
because they are weak, either cause no disease or only mild form. Usually,only one dose of this

47
type of vaccine provides life-long immunity,with the exception of oral polio accident, which
requires mullet doses.Examples-
 ▶Viruses OPV,MEASLES,YELLOW EVER
 ▶BACTERIA-BCG,Oral typhoid,oral cholera

b)INACTIVATED VACCINES:-Are produced by growing viruses or bacteria and the inactivating

them with heat or chemicals. Because they are alive, they can not grow in a vaccinated
individual and therefore can not cause the disease. Since they are not as effective as live
vaccines ,multiple doses are required for full protection. Booster doses are needto maintain
immunity

c)Recombinant: are produced by inserting genetic material from a diseas-causing organisms

into harmless Dee,which replicates the proteins of the diseas-causing organisms. The proteins
are then purified and used as vaccines

NATIONAL IMMUNIZATION SCHEDULE

The Kenya National immunization schedule consists of five contacts between birth and 9
months. If a child is seen for the first time later than the schedule age,the child must catch up
with immunization. All the vaccines for which the child is eligible at an earlier age can be given
together any time you come in first contact with the child.

- [x] TUBERCULOSI-At birth or before 2 weeks:-BCG and Oral polio

- [x] Week 6:-OPV1,DPT/HepB/HIB q,PCV 1,-polio,haemophilus influenza,
pneumococcal,hepatitis B,measles,rota virus,yellow fever
- [ ] Week 10:-OPV 2,DPT/HepB/HIB 2,PCV2
- [ ] Week 14:-OPV 3,DPT/HepB/HIB 3,PCV 3
- [ ] Month 6:-VIT A
- [ ] MONTH 9:-Measles,yellow fever
- [ ] ROTA VIRUS :- Before 6 weeks,and 10 months

DISEASES TO BE IMMUNIZED
o [x] TUBERCULOSES
o [x] DIPHTHERIA
o [x] PERTUSSIS
o [x] TETANUS
o [x] HAEMOPHILUS INFLUENZA TYPE b disease
o [x] Hepatitis B
o [x] Measles
o [x] Polio
o [x] Pneumococcal disease
o [x] Rota virus diarrheal disease
o [x] Yellow fever

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VACCINE TYPES AND ADMINISTRATION
1. TETANUS:deep I.m 0.5mls. For children and under 5 ,it is given in three doses at monthly
intervals in combination with penta- valent and they should be separated by one month. For
expectant mothers, 1st pregnancy;the first dose is given in 2nd trimester and they should be 2
doses and gives a protection of 1-3 years. In second pregnancy protection is for 5 years. Third
pregnancy the protection is for 10 years. 5-TT FOR FANC,5TT FOR GIRLS AND WOMEN OF
CHILD BEARING AGE(CBAWS),5-TT FOR TRAUMA AND OCCUPATIONAL PROPHYLAXIS,5-TT
SCHEDULE FOR SCHOOL AGED CHILDREN
2. BCG vaccine- intradermal where a small nodule appears and may develo,as a small ulcer and
late r become a scar.
3. Penta valent vaccine(DPT-HepB+Hib)- contains five vaccines namely
diphtheria,pertussis,tetanus,hepatitis B,and haemophilus influenza type b .dose is 0.5mls.Im.
4. POLIO:- sublingual
5. Measles:- 0.5 I'm.SOME TIMES CHILDREN WHO HAVE BEEN IMMUNIZED AGAINST MEASLES
DEVELO IT BECAUSE: (a)The child may not have measles but some other viral infection with a
similar rash and fever.(b) Measles vaccine that has lost its potency due to improper storage that
may have been used. (C) The child immunized may have been too young {<9months}and so
have a lot of antibodies from the mother.
6. Yellow fever :- sc 0.5
7. Pneumococcal vaccine
8. Rota virus
9. PCV

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 LESSON 10:
Cold chain system, Repair and maintenance of cold chain equipment; infection prevention;Epi disease
surveillance- EPI target population,vaccine requirements;National immunization days.

COLD CHAIN
Cold chain is the process of maintaining vaccines in a potent state from the manufacturer to the
recipient (child and woman of child bearing age). Vaccines lose their potency when exposed to
high temperatures,sunlight or freezing conditions depending on type.
COLD CHAIN EQUIPMENT
 Cold rooms and freezers
 Freezers and ice lined refrigerators
 Gas electric refrigerator
 Solar refrigerator
 Vaccines carriers
 Cold boxes
 Icepack
 Thermometer
REPAIR AND MAINTENANCE OF COLD CHAIN EQUIPMENTS
- Check the temperature twice in the morning and in the evening
- Check that the refrigerators is operating and the burner flame is blue for gas refrigerator
- Make sure that there is enough gas in the cylinder
- Ensure that the vaccines are well arranged in the refrigerator
- Do not keep any other item in the refrigerator
- Keep a spare gas available and always replace the gas cylinders before it is completely empty.
INFECTION PREVENTION
what is a safe injection? A safe injection is the one which does not harm the recipient,nor
expose the health worker and the community to any risk.
An injection is considered safe for:-
 The mother or child when a health worker uses a sterile syringe and a sterile needle and
appropriate injection technique
 The health worker ,when he or she avoids needle stick injuries and
 Community, when waste created as a result of used injection equipment is disposed off
correctly and does not cause harmful levels of pollution and injuries.

What is unsafe injection? An unsafe injection is one that can result in transmission from one
patient to another such infectious complications such HIV/AIDS,Hepatitis B and C malaria .
Some common injection practices that can cause harm to the recipient

50
- Re-using syringe or needle
- Changing needle but re-using syringe
- Loading syringe with multiple antigens and injecting multiple persons
- Leaving the needle on the vial for withdraw of additional doses
- Touching sterile parts of syringe and needle
- Applying presumably to bleeding injection the with used materials and dirt f Ingres
- Storing medication and vaccines in the same fridge
Practices that can harm health worker
- Recapping
- Placing used needles on the surfaces or carrying them from one point of use for disposal at a
designated area.
- Sorting out mixed health care wastes.
- Using injection equipment for non -injection purpose
Practices that harm the community
- Leaving used syringes and needle in un protected areas where they can be easily accessible to
children and grazing animals
- Community ca be at risk when injection equipment is carelessly disposed off and because of
it's commercial value,it can be retrieved,resold and reused.

STEPS USED TO ADMINISTER VACCINES

This is by use of equipments which are appropriate to administer vaccines:
a). AUTO-DISABLE(AD) Syringes:- Are self locking syringes that are only used at once.
b).PRE-FILLED INJECTION DEVICES:- used only at ounces for some antigens

IMMUNIZATION WASTE MANAGEMENT

Waste are materials or products made useless for any further use
TERMINOLOGIES USED IN WASTE MANAGEMENT
- [ ] SEGREGATION:-This is the separation of wastes at a point of generation into different and
distinct containers or bags according to national color codes. Segregation should be separated
in to harmful ((hazardous)and non-hazardous waste. Proper waste segregation should be able
to minimize hazardous waste requiring special handling.
- [ ] SAFETY BOX:- A safety box is a leak and puncture proof container that carries 100 syringes
when 3/4 full. A safety box is filled to 3/4 full level to avoid spillage,needle stick injuries and to
ease the sealing of safety box and should be stored safely awaiting transportation to the central
disposal site.
Safety box precautions
- Do not open used safety boxes or empty it for re-use
- Do not squeeze or force syringes inside the safety boxes .should filled to ¾ full.
- [x] COLOR CODING:- This includes
 Yellow colorfor hazardous waste
 Blackfor Non-hazardous wastes
 Red bag for infectious waste
 Sharps should be disposed into the safety boxes Immediately at point of use

51
SAFE WASTE DISPOSAL
 INCINERATOR: A structure constructed of bricks for burning of waste
 Incineration
 Burning

Role of waste handlers

 To collect boxes, and deliver them to the disposal site
 To load the incinerator/burn/bury the waste depending on the disposal method used
 Ensure safe final disposal of wastes

Requirements for waste handlers

 Heavy duty gloves
 Goggles
 Mouth mask
 Boot
 Rake and fire pokers
 Wheel burrow
 Fire resistant overcoat
 Ash removal spade with long arm handle
 Helmet

ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

The goal of immunization in Kenya is to protect the public from vaccine preventable disease.
Modern vaccines are safe ;although after immunization,some people may experience
reactions;ranging from mild local reactions to life threatening illnesses.

Definition of AEFI:-is a medical incident that occurs during or after an immunization and is
believed to be caused by immunization. Health workers should detect and report the following:
 Anaphylactic shock
 Injection site abbess
 Case of BCG lymphadenopathy
 Case which need hospitalization and are related to immunization
 Death or medical incidents and are thought to be related to immunization
IDENTIFICATION OF AEFI
 Itchy,urticaria rash
 Progressive,painless swelling about the face and the mouth,which may be preceded by
itchiness,tearing,nasal congestion at facial flushing .
 Respiratory symptoms including sneezing,coughing, wheezing and DIB.
 Hypotension
STEPS OF MANAGING ANAPHYLAXIS ARE:-
* Place the patient in a recumbent position

52
* Establish an oral air way if necessary
* Check respiratory and pulse
* Administer epinephrine by subcutaneous or intramuscular
* Monitor vital sign
* Arrange for transfer to an emergency

INJECTION ABCESS
Signs of injection access are swelling or hard nodule at the injection site. That may progress into
painful swelling and burst into a wound. Manage the abscess and reassure the patient.
Causes of AEFI
 Programmatic errors like handling or reconstitution or administration .
 Nature of the vaccine or individual response.
 Coincidental -an event that has no causal association between the immunization and
the medical condition of the child or woman.
 Unknown cause
Why AEFI is an important area to address in immunization
EPI DISEASE SURVEILLANCE
An AEFI may upset people to the extent that they refuse further immunity for their children.
* Their refusal to accept the vaccine puts children at risk of vaccine -preventable disease and
their consequences.
* The health work should be able to diagnose,treat and report all AEFIs

Immunization of HIV positive child

They should receive all immunization according to EPI Schedule except when they have
symptoms they are not given BCG and Yellow fever vaccine.

EFFECTS OF A MOTHER's ANTIBODIES

An important consideration when deciding at what time to vaccinate babies is whether the
baby has antibodies from the mother. Vaccines should not be given to a baby who still has
antibodies from the mother because he r antibodies will inactivate the vaccine before it can
stimulate the immunity. This wastes vaccine and mothers think that their babies are protected
when they are not.
The leghth of time these antibodies from the mother remain in the baby's bloods varies for
different reasons
 antibodies against BCG do not cross over to the baby so this vaccine can be given at
birth.
 antibodies against polio,and diphtheria pertussis and tetanus do pass to the baby if the
mother had this diseases or had been immunized for the same. However,they remain
for only a few weeks hence the vaccine can be given when the baby is aged one month.
 In case of tetanus,this passive immunization from the mother can provide very
important protection against tetanus in the newborn. These antibodies can be provided
by giving the mother injection of tetanus toxoid during her pregnancy. She then quickly
develops antibodies and these protects the baby. Neonatal tetanus infection occurs if

53
 the umbilical cord, or any other part of the baby's body becomes infected with tetanus
organisms.
 Measles antibodies from the mother remain longest in the new born ,usually up to age
9 months hence the vaccine is effective when given after nine months. However,some
children develop measles between 6-9 months because antibodies from the mother do
not remain at a high enough level to protect them completely.

DATA MANAGEMENT,MONITORING AND EVALUATION IN

IMMUNIZATION
MONITORING :- is a systematic and continuous process of examining processes,procedures
and practices within a program. The focus of monitoring is therefore day to day activities within
a program with the aim of identifying problems and developing solutions. Because it is a
continuous process,data used for monitoring is therefore collected ,reported,analyzed and used
routinely as defined by the program.
EVALUATION:- This is a periodic assessment of the overall program performance. An evaluation
aims to measure the program performance against its objective at specific times
PERFORMANCE:-level of fulfillment of operational capacity of a person or program
ACTIVITY:- a task or set of interrelated tasks aimed at generating a product or a result.
INDICATORS:- this is a variable used to compare program performance against its stated
objectives.

DENOMINATORS [TARGET] OF IMMUNIZATION COVERAGE

To be able to conduct monitoring and evaluation process ,one must first set the target to be
achieved. This are
 0-11 months old for (population <year old) for primary infant population
 Pregnant women (expected deliveries) for vaccinate with tetanus toxoid
 Women of child bearing age in those place tetanus is considered as risk
At the beginning of each year, every facility must calculate the number of children and women
to be vaccinated with each antigen.

ROUTINE IMMUNIZATION INDICATORS

Indicators are variables used to compare performance in terms of efficiency,effectiveness and
results. They are:-
* Convert raw data into useful information
* Mark progress toward defined target
* Describe the situation and measure changes over time
* Provide information about a broad range of rough a single measure
* Enable comparisons between different facilities

54
Target:is a number of an indicator that represents a specific objectives to be achieved over a
specified period of time.
indicators usually used in routine immunization ae:-
 Immunization coverage:-This is the measure of the extent to which the services being
rendered cover the potential need for these services in the community. It is the
proportion of vaccinated individuals among the target population.

 Coverage formula = number of individuals vaccinated ❌ 100/Number of individuals

targeted for vaccination
You routinely calculate:- coverage for each dose,coverage for immunized child and ?TT2
coverage
 Drop out rates:- is the number of individuals who start an immunization schedule but
fail to get the last/antigen on the schedule. For example if a woman brings her child for
DPT-Hep B+Hib1 and OPV 1 but does not return for other childhood immunization,her
child is considered a "DROP OUT”
 Completeness:- means all the required fields in the report have been filled or the
proportion of reports received.
 Timeliness reports: proportion of reports which are received in time. It is the number of
reports received on time / Total reports expected. Data collected from the tally sheets
needs to be summarized, for action at health facility level and transmitted to the county
level by 5th of the following month. Th county then uploads the data on DHIS WEBSITE.
When reports Re sent and received on time,the possibility of a prompt and effective
response is greater.
Collecting routine immunization data
All immunization must be accurately recorded at the health facility. This will allow accurate
calculations of the coverage for different antigens as well as assist I'd defaulters tracing where
necessary. So as to monitor immunization activities well the following tool should be available
at each immunization facility.
 Mother and child health booklets
 Immunization tally sheets
 Immunization permanents register
 Immunization and vitamin A summary sheet
 TT Permanent register
 Tracking systems to monitor defaulters
 Immunization monitoring chart
 Data quality self assessment
 Immunization survey

Disease surveillance
Is the collection,analysis,and interpretation of data to determine disease trends and patterns.
Disease surveillance provides information such as:
 Disease incidents,morbidity and mortality and progress in achieving disease control
goals.

55
  Change in patterns of morbidity and mortality among different age groups in different
geographical areas and among different economic,social or cultural groups.
 Impact of immunization strategies and disease incidence .
 Diseases trends
The overriding value of disease surveillance,however ,is its use as a tool to identify the presence
of infectious disease and guide actions to prevent them from becoming threats to public
healthcare

Types of Disease surveillance

 Facility based routine surveillance:- Health workers are required to report on the
number of individuals that come to their facility and are diagnosed with notifiable
disease. The process of detecting and reporting information on diseases that bring
patients to the health facility is known as passive surveillance
 Community-based surveillance:- with proper training ,member of the community can
expand facility based surveillance by detecting and reporting cases that may go
undetected by the health facility .
 Sentinel surveillance:- Sentinel surveillance is the collection and analysis of data by
designated institutions selected for their geographic location,medical specialty,and
ability to accurately diagnose and report high quality data.
SURVEILLANCE ACTIVITIES
surveillance for communicable diseases involves:
* Detection
* Investigations
* Reporting
* Analysis and interpretation
* The presentation
* Response
1. Detection:-Surveillance begins with case detection. To accurately detect disease,health
workers need case definitions that are appropriate for the local context ,and they need practice
in applying them,especially when they do not see a specific illness very often such in the case of
polio. Even with appropriate case definition,clinical diagnosis can be a problem.Many illness
have similar symptoms,such as fever and rash,and can be differentiated only by laboratory tests
that may not be accessible. In every facility,there should be a focal person who should
coordinate through availing the specimen collection tools,carry out Active Case search and then
communicate to sub county disease surveillance coordinator.
2. Investigational reporting:- Ministry of Health through HMIS requires that facilities routinely
report the total count of cases of each reportable disease that occurred within a specified time
usually monthly in the MOH 719. When no cases have occurred during the period,the report
should indicate this fact (Zero report).
3. Analysis and interpretation:- surveillance data are of little use for local decision-making and
planning unless health workers know how to analyze the data and understand their
implications. Health workers need to be able to interpret trends and patterns of disease in
order to enact prompt control measures and avoid actions that are not appropriate. In order to

56
analyze and interpret surveillance data,health workers need to be aware of the limitations and
peculiarities of the data set. Presentations can be done using graphs,tables maps etc
4. Response:- Disease surveillance enables mangers to respond to existing problems and take
steps to prevent anticipated problems. Responses may include verification of reported
cases,treatment ,search for new cases ,or supplemental vaccinations activities,but all must be
tailored to the disease and the situation.

Standard case definitions

Ministry of health has 19 notifiable diseases: This are:-
- Keeping currently has target of three diseases- polio (AFP) measles,neonatal tetanus for active
surveillance
- EPIDEMIC PRONE DISEASES ARE:- measles,yellow fever
- Disease targeted for eradication are :-acute flaccid paralysis AFP/polio
- Diseases targeted for elimination:- measles and Neonatal tetanus

MEASLES:- Any person with fever and macula-popular generalized rash and cough ,coryza or
conjunctivitis
ACUTE FLACCID PARALYSIS(AFP)/POLIO:- weakness of flopping essay of sudden onset,not due
to trauma, in a child less than 15 years of age or in any case in which clinician suspects poli
NEONATAL TETANUS:- Normal suck&ecru for the first 2 days of life plus onset of illness
between 3&28days plus inability to suck followed by stiffness and convulsions.
YELLOW FEVER:-Any person with sudden onset off high fever >39C followed by jaundice within
two weeks of onset of first symptoms

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 LESSON 11:
FOCUSED ANTENATAL CARE: Defination,goals,justification,component of FANC

FOCUSED ANTENATAL CARE

Definition:- Antenatal care is the care given to a pregnant woman from conception to the onset
of labour.
AIM
To achieve a good outcome for the mother and baby and prevent any complications that may
occur in pregnancy,labor,delivery and the post Portugal periods.
The approach:-
The risk approach to antenatal care has not resulted in significant improvement in maternal
survival. Health care complications of pregnancy are difficult to predict with any degree of
certainty. Health care providers must,therefore,consider the possibility of complications in
every pregnancy and prepare clients accordingly.
While risk assessment can help direct counseling and treatment for individual,it is important to
understand that most women who experience complications have no "risk factors "at all.
FANC:FOCUSED ANTENATAL CARE: or targeted ANC refers to a minimum number of four
personalized clinic visits each of which has specific items of clients assessment,education and
care to ensure prevention or early detection and prompt management of complications. The
focus is on birth preparedness and on individuals in readiness to handle complications.
GOAL AND JUSTIFICATION
Women can benefit from just a few antenatal visits, as long as those visits are thorough.
Focused or targeted ANC refer to a minimum number of four comprehensive personalized
antenatal visits,each of which has specific items of clients assessment,education and to ensure
prevention or early detection and prompt management of complications. Always view each visit
as if if it were the only visit the woman may make. Many women can not come for 4 visits.

ANC should be simpler,safer,friendly and more accessible. Women are more likely to seek and
return for service if they feel cared for and respected by the providers. This personalized
approach requires health care providers to use excellent interpersonal skills since listening to
clients concerns is just as important as giving advice. It respects clients right to
dignity,privacy,confidentiality,full and accurate information.

OBJECTIVES
 Early detection and treatment of problems
 Prevention of complications using safe ,simple and cost effective
intervention
 Birth preparedness and complication readiness
 Health promotion using health messages and counseling

58
  Provision of care by a skilled attendant
COMPONENTS OF FANC
SCHEDULED VISITS
It is recommended that the pregnant woman should attend a minimum of four comprehensive
personalized antenatal visits spread out during the entire pregnancy during which specific doc
use activities are carried out to guide the women along the path of survival,as follows:
 First visit less than16 weeks
 Second visit 16-28 weeks
 Third visit 28-32 weeks
 Fourth visit 32-40 weeks
However,depending on individuals needs,some women will require additional visits.

The purpose of focused antenatal care is to promote health and survival through:
 Assessment
 Treatment
 Prevention
 Promotion
Assessment of women attending antenatal clinic is done by history taking ,physical
examination and laboratory/investigations
First visit:-
Content of the first visit:
A] Obtain information on:
i. Personal history
 Name
 Age (date of birth)
 Physical address and telephone numbers
 Marital status
 Education level:primary,secondary,tertiary-college,university
 Economic resources:employed,type of work,position of patient or guardian.
 Tobacco use (smoking or chewing) or other use of harmful substances
 History of present pregnancy
 Date of last menstruated all period(LMP),HX oF contraception use. Determine the
expected date of delivery based on LMP and all other relevant information. Use
280 day rule (LMP+280 days)
 Malaria attacks
 Quickening if applicable
 Any expectant event ( pain,vaginal bleeding,others)
ii. Obstetrics history
 Number of previous pregnancies
 Date and out comes of each event (live births,still births,neonatal death,abortion)
 Birth weights
 Sex of the baby

59
  Period of exclusive b/feeding
 Any complications
iii. Obstetrics operations
 Cesarean section
iv. Special perinatal complications
 Twins
 Low birth weight< 2500
 Big baby >4000
 Intrauterine growth retardation
 Malformed child
 Resuscitation or other treatment of the new born
 Neonatal Death
v. Medical history's
 Specific diseases and conditions
o TB,heart disease,chronic renal disease,Diabetes
o RTIS
o HIV status
o Other specific conditions depending on prevalence in the
region,hepatitis,malaria and sickle cell
 Blood transfusion
 Operations other than CS
 Current use of medicines
 Period of infertility when? Duration
 Any other diseases,past or chronic;allergies
B]PERFORM PHYSICAL EXAMINATION
 General appearance
 Head to toe examination
 Measure blood pressure,pulse rate,temperatures and weight ,height
 Check for sign of anemia: pale complexion,conjunctiva,oral mucosa,,tip of the tongue
and shortness of breath
 Examine the breast and the chest and auscultation
 Measure the fundal height
 Look for signs of CS
 Foetal well being using foetal movements and heart sounds.
 LOOK AT THE EXTERNAL GENITALIA for warts,discharges
C]PERFORM THE FOLLOWING TESTS:
 URINE- sugar,acetone,protenurua
 Blood- VDRL
 Blood group ABO and Rhesus factors
 HB
 PITC

60
  SPUTUM
D]IMPLEMENT THE FOLLOWING
 Iron and folic acid to all women
 If test for syphilis is positive: treat
 Tetanus toxoid
 Refer women when complications arise that cannot be mangled at the facility,eg:
 Severe anemia,HB< 7.0 g/m
 Antepartum hemorrhage
 High BP>140/90
 IUGR
 Under weight
 TB
 HIV POSITIVE
 If the first visit is after 16 weeks,give:
 In malaria endemic zone sulfa dioxine and puremethamine SP 3tabs(intermittent
preventive therapy)
 Mebendazole 500mg

E] Asses the need for specialized care

Determine whether the woman is need of special care and / or referral to a specialized clinic or
hospital
 Diabetes
 Heart disease
 Renal d
 Epilepsy
 Drug abusers
 Family history of genetic diseases
F]DEVELOPMENT OF INDIVIDUAL BIRTH PLAN
Assist the pregnant woman to develop and individual birth plan ( IBP). Encourage the male
partner to be involved in the health care of themother to plan for his baby and what they
should know:
 EDD
 The danger signs pregnancy,child birth and the post pursue period
 The danger sign for the newborn
 She should decide on who will be the skilled attendant and where
 She should be advise to identify birth companion
 What transport she will use before,during labour and after delivery I'd complications
arise
 How she will raise funds for transport
 Identification for possible blood donors incase of emergency
 Her post purtum contraception

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  For bad obstetrics history like previous CS, STILL BIRTH,Retained placenta/PPH, they
should be advise to deliver at the hospital.
 Where multiple pregnancy has been diagnosed,the woman should be referred
immediately .
G] advice on complications and danger signs
Assessments of women attending antenatal to clinic is done by history,physical examination
and laboratory tests/investigation.
while risk assessment can help direct counseling and treatment for individual,it is important to
understand that most women who experience complications have no risk factors at all.
note : Every pregnant,deliveries or post purtum woman is at risk of serious life threatening
complications.

The following "high" criteria imply the need for careful monitoring to help prevent a possible
complications from arising or to enable its early detection and management.
 poor obstetrics history
 strikingly short stature
 very young maternal age (below 15 years)
 size date discrepancy
 unwanted pregnancy
 multiple gestation
 abnormal lie/presentation
 nulliparity
Danger signs in pregnancy
 Bleeding per vagina
 Bleed
 Drainage of liquor
 Severe abdominal pains
 Severe headache
 Generalized body swelling
 Reduced fetal movement
 Convulsions
Danger sign in labour
 Labour pains for more than 12 hours (sun rise to sun set)
 Excessive bleeding
 Ruptured membranes
 Convulsions in labour
 Loss off consciousness
 Cord,arm,or leg prolapse
Danger signs in postpartum period (mothers)
 Excessive bleeding
 Fever
 Foul smelling discharge
 Abdominal cramps

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  Painful breasts of cracked nipples
 Mental disturbance
 Extreme fatigue
 Headaches
 Convulsions
 Painful calf muscles
Danger sign in postpartum period (new born)
 Fast breathing more than 60 breaths per minute
 Slow breathing. Less than 30 breaths/ minute
 Severe chest in drawing
 Umbilicals draining pus
 Floppy or stiff
 Fever
 Convulsions

HEALTH PROMOTION
 Advice on personal hygiene,rest nutrition,FP,malaria, worm infestation,
HIV/AIDS and PMTC
 Give advice on safe sex
 Advise women to stop using tobacco,alcohol and other harmful substances
 Counsel on breast feeding including breast self examination
 Advise the woman to bring her partner
 Schedule appointments as per recommendations
 Maintain Clean record and give out the ANC BOOKLET and advice the
mother to be coming with it every time she attends the clinic.

SECOND VISIT
YOU TAKE HISTORY AS ABOVE,DO PHYSICAL EXAM, REVIEW RESULTS AND TAKE THE NECESSARY
ACTION,AND ADVICE
Check on the an individual birth plan
Counsel and educate

THIRD VISIT
AS ABOVE.REASSES

FOURTH VISIT : as above and REASSESS

PREVENTIVE CARE DURING ANTENATAL CLINIC
 Tetanus toxoid immunization
 Micronutrients including iron,folate and vitamin A ,iodine and calcium
 Malaria prophylaxis or intermittent presumptive treatment using appropriate anti
malarial

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Health promotion in the antenatal period
This includes:
 Health education and counseling the pregnant woman on how to look after herself
personal hygiene ,rest, nutrition,breastfeeding ,family planning,sexually transmitted
infections,malaria,worm infestation,danger signs
 HIV/AIDS and PMTCT
 Clients participation including husband (partners), mother in law,sisters and other
care givers
 Birth preparedness: place,skilled professionals attendant, Essential items for clean
birth
 Complications readiness plans: emphasize readiness at all times,not to wait until the
last week of pregnancy,emergency funds,transport and communications
 Assisting every pregnant woman to have a plan for accessing emergency care.

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 LESSON 12:intermittent preventive therapy, Danger signs, individualized birth plan, antenatal
examination, screenings 4 visits, PMTCT,
INTERMITTENT PREVENTIVE THERAPY
PREVENTION OF MALARIA IN PREGNANCY
The goal of prevention of malaria in pregnancy is to reduce maternal and perinatal morbidity
and mortality associated with malaria. The strategies in prevention of malaria in pregnancy are
integrated in the overall antenatal care (ANC) package for maternal health. They include the
provision of:
 Intermittent treatment for malaria in pregnancy (IPTp)
 Long lasting insecticide Nets
 Provision of prompt diagnosis and treatment of fever due to malaria
 Health education
INTERMITTENT PREVENTIVE TREATMENT OF MALARIA IN PREGNANCY (IPTP)
IPTp is the presumptive (regardless of whether the woman is infected or not) provision of a full
treatment course of an efficacious an malarial at specific intervals during pregnancy. IPTp has
been shown to reduce the risk of placental infection on and the associated risk of maternal
anaemia, miscarriage, premature deliveries and low birthweight. The current recommended
medicine for IPTp is 3 tablets of sulphadoxine/ sulphalene 500mg and pyrimethamine 25mg.
 IPTp is recommended in areas of high malaria transmission
 Administer IPTp with each scheduled visit a er quickening to ensure women
receive a minimum of 2 doses
 IPTp should be given at an interval of at least 4 weeks (1 month)
 IPTp should be given under directly observed therapy (DOT) in the antenatalclinic and
can be given on an empty stomach.
 SP as IPTp is safe up to 40 weeks pregnancy and late dosing is beneficial forwomen
presentation in pregnancy
 Folic acid tablets should NOT be administered with SP given for IPTp and ifneed be, may
be taken 14 days following administration on of IPTp
IPTp and HIV+ pregnant women
HIV infection during pregnancy increases the risk of the complications of malaria in pregnancy
while malaria infection during pregnancy particularly placental malaria increases the risk of
mother to child transmission of HIV.
Pregnant women who are HIV positive and are on daily cotrimoxazole chemoprophylaxis should
not be given SP for IPTp
• Pregnant women who are HIV positive and are also taking an retroviral therapy for PMTCT
who are not receiving cotrimoxazole should receive IPTp with SP.
• Women known to be HIV infected or with unknown HIV status living in areas of high HIV
prevalence ( >10% among pregnant women) should receive at least 3 doses of IPTp.
 In malarial endemic areas, it is important to give treatment for malaria. We treat
women for malaria because we know from many studies that most of the time she
probably has malaria and that she needs protection.

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Long lastinginsecticide treated nets
• LLINs are key in the prevention of malaria in pregnancy.
• Each pregnant woman living in a malaria risk area receives a free LLIN atthe first contact visit
to the ANC
• Each pregnant woman is shown how to hang the LLIN and encouraged touse the net each and
every night during her pregnancy and thereafter.
• LLIN are not a substitute for IPTp and vice versa. Both must be used in order to achieve
maximal benefits in the reduction of both maternal andperinatal morbidity and mortality

HEALTH EDUCATION
• continuous maternal health education should be provided at the ANC encouraging use of all
intervention and services and encouraging the pregnant woman to a end all ANC visits as
scheduled.

DANGER SIGNS:
 Danger signs in pregnancy
 Danger signs in labour
 Danger signs in postpartum
INDIVIDUALIZED BIRTH PLAN
1. The plan should take account of:
 The woman's preference for place of birth and skill level of birth attendant.
 Family support
 Assessment of a woman's risk of complications during labour and delivery
 Assessment of satisfactory arrangements of transportation incase of emergency
referral,and distance
 Economic status
 Essential items required for delivery/care of the baby.
2. Tetanus toxoid immunization
3. Intermittent presumptive treatment using SP
4. Home based maternal records (booklet)
5. Timing of next visits
6. Iron and folic supplementation
ANTENATAL EXAMINATION
 History
 Physical examination
 Health promotion
 Laboratory and radiological investigation
SCREENINGS 4 VISITS
1st visits:
 Advice on individuals birth plan
 Take history
 Do physical examination

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  Look for anaemia
 Screen for syphilis
 Give TT,iron and folate
 Give SP if more than 16weeks
 Tell her about danger signs.
2nd visit
 Check on individual birth plan
 Give first SP,iron and folate
 Listen to foetal heart sounds
 Counsel and educate
rd
3 visit
4th visit

PREVENTION OF MOTHER TO CHILD TRANSMISSION- PMTCT

The prevalence of HIV infection in women is almost twice that in men: Though the prevalence
of HIV infection is declining,MTCT will remain a significant source of infection for children in
Kenya unless effective interventions are used to prevent it. In Kenya ,MTCT accounts for more
than 90% of HIV infection in children.
Without any interventions, the risk of an HIV-infected mother passing the virus to her infant
during pregnancy,labour and delivery or in the postnatal period is 1:3.
IMPACT OF HIV INFECTION ON PREGNANCY
 Increased pregnancy loss
 Preterm deliveries
 Low birth weight
 Increased rate of still birth deliveries
 HIV associated conditions such as TB,UTI.
MOTHER TO CHILD TRANSMISSION OF HIV
 In delivery and labour,transmission is high due to the increased exposure of the new
born to HIV contaminated blood and body fluids.
 Prolonged breast feeding
 Prematurity
 Low birth weight mastitis
 Genital tract infections
 High viral load
 Low CD4 count
INTERVENTIONS TO REDUCE MTCT
 Prevention of HIV infection among all women of reproductive age group from getting
HIV .
 Prevention of unintended pregnancies among HIV positive women.
 Effective interventions to reduce HIV transmission to infants during pregnancy,labour
and deliver and post care.
 Chronic care and support for the infected women ,their infants,partners and families .

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 LESSON 13:
Infection prevention

INFECTION PREVENTION
Learning objectives
-Define infection prevention
-Describe disease transmission cycle
-Explain the purpose of infection prevention
-Explain the principles of infection prevention
- Describe the hand washing technique
-Explain the administration of multi-dose medication and needle recapping technique

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-Describe the procedures used to process instruments
-Describe the procedure of waste disposals
TRAINING NEEDS
Knowledge required
i. Definition of infection prevention
ii. purpose of infection prevention
iii. Knowledge on disease transmission cycle
iv. Explanation of the infection prevention principles
v. Basic infection prevention methods
vi. Procedures used to process equipment
vii. How to make a chlorine solution
Skills required
1. implementation of infection prevention measures
2. Demonstrate appropriate infection prevention practices at all times.
Attitude require
Health care workers would appreciate that infection prevention practices go along way to
reduce transmission of micro-organisms and that improvements need to be made in infection
prevention and control in our workplaces
Rationale
Evidence has shown that inpatients, members of clinical staff acquire infections from the
hospital environment e.g.about 9% inpatients acquire infection at any time equivalent to at
least 100,000 infections a year in England.According to CDC,5% of all patients in US hospitals
develop infections ;at leas 1/3 of these infections are preventable. The rates are much higher in
developing countries where resources for health care are limited.
Annually,nosocomial infection affect more than 2 million persons in the US. Infection account
for 50%of major complications;medicate errors,patient falls,and other non-infectious adverse
events account for the rest. Healthcare associated infections and other adverse events are
recognized as critical problems affecting the quality and cost of healthcare.

Infection prevention measures are important in all health care situations. Therefore health care
providers should take precautions when performing maternal and newborn health procedures
to minimize personal risks from exposure to blood and body fluids.
Even when a sterile techniques is use for delivery,infection can still occur from patients
endogenous bacteria if they are brought into the uterus by examining fingers,or by the
instruments during pelvic examinations or other vaginal procedures or by foreign bodies that
are inserted involved angina e.g.herbs,oils,cloth or by sexual intercourse.

Definition of common terminology in infection prevention

1. Infection prevention:-is a collective effort made by healthcare providers and clients to
prevent or minimize the risks of transmitting infections such as Hepatitis B and HIV/AIDS and
bacteria to clients or to other healthcare providers

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2. Decontamination:- Is the first step in the infection prevention process. It is important to
decontaminate soiled surgical instruments, surgical gloves and other items before cleaning by
placing them in 0.5% chlorine for 10 minutes
3. Cleaning:- is the process of physically removing all organic materials, such as
blood,tissues,sputum,feaces and urine.
4. High-level disinfection(HLD):- refers to the destruction of all micro-organisms with the
exception of high level of bacteria spores. A disinfectant is used.
5. Sterilization :-is the process in which all micro-organisms including endospores are
destroyed.
6. Hazardous wastes:-include blood,pus,urine,stool and other body fluids. Also includes
dressings and wastes fro theaters and laboratories.
7. Non-hazardous waste:-does not carry infectious risk to persons handling them. This includes
paper,rubbish,boxes.
8. Sharps:- are items capable of inflicting injury because they are "sharp"and may contain the
organisms that cause blood borne diseases such as hepatitis B and HIV.

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Disease transmission cycle

THE PURPOSE OF INFECTION PREVENTION

The primary purpose of infection prevention in health care facilities,where free standing or
mobile is two folds:
 To minimize infection due to microorganism causing serious wounds
infections,abdominal abscess,pelvic inflammatory disease,gangrene or tetanus.
 To prevent the transmission of serious,life threatening disease such as hepatitis Band
HIV/AIDS.
PRINCIPLES OF INFECTION PREVENTION
The recommended infection prevention practices are based on certain important principles:-

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  Every person(patient or staff) must be considered potentially infectious
 Hand washing is the most practical procedures for preventing cross-contamination
 Wear gloves before touching anything wet-broken skin,mucous membranes,blood or
other body fluids(secretions or excretions)
 Use barriers (protective goggles,face masks or aprons) if splashes and spills of any fluids
(secretions are excretions) are anticipated.
 Apply safe work practices such as not recapping or bending needles,proper instruments
processing and proper disposal of hospital wastes .
Basic infection prevention methods
The basic infection prevention methods are:-
 Hand washing
 Decontamination
 Cleaning
 High level disinfection (HLD)
 Sterilization.
 Storage
 Waste disposal
1. Hand washing:is the physical removal of dirt,organic materials and transient microorganism
from the hands by use of way, soap and frictions. It removes 99%of transient bacteria. This is
the single most important procedure and most practical way of preventing cross contamination.
Do not dry hands with common towel.
When to wash hands:-
 Many time hands are visibly soiled
 Before touching any clients who are unusually susceptible to
infection,newborns,immuno compromised infants a or adults
 Before doing any surgical procedure
 After touching inanimate objects such as soiled instruments
 After contact with a source of micro-organisms e.g.blood,body
fluids,secretions,broken mucus member.

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PROCEDURES FOR PROCESSING INSTRUMENTS

Waste disposal
Waste is unwanted material arising out of health care provision activities.
Types of wastes:
 Non-contaminated waste include paper,trash,boxes,bottle and plastics containers
 Contaminated waste includes blood,pus, urine,,stool,used dressing and other body
fluids
Purpose of waste disposal
 To prevent the spread of infection to health service providers
 To prevent the spread of infections to the local community

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  To protect those who handle wastes from accidental injuries
Proper handling means:-
 Wearing utility gloves
 Transporting solid contaminated waste for disposal in covered container
 Disposing all sharps items in puncture- resistant containers
 Burning or burying contaminated waste

HEALTH CARE WASTE

- [x] Definition of health care waste
- [x] Health care waste management
- [x] Importance of health care waste
- [x] Categorization of health care waste
- [x] Principles of health care waste
- [x] Key steps in health care waste
Health care waste includes all the waste (solid,liquid or gases) generated by healthcare
facilities,research facilities,and laboratories,and it includes the wastes originating from "minor"
or "scattered"sources ,such as that produced in the course of health care undertaken in the
home (dialysis,insulin injections etc)
HEALTH CARE WASTE MANAGEMENT
The term waste management means the classification,collection,transport,treatment ,recycling,
or disposal of waste ,including the supervision,of such operations and after care of such
disposal sites.
IMPORTANCE OF HEALTH CARE WASTE
 To minimize the effects on public health such as disease transmission and injuries
caused by sharps.
 To reduce the environmental impacts caused by pollution resulting from improper
disposal.
 To prevent risks and hazards to waste handling staff.
 To reduce the costs resulting from waste handling

CATEGORIZATION OF HEALTH CARE WASTE

Health care waste is broadly classified as hazardous and non-hazardous. Hazardous health care
waste has the potential to cause harm to both humans and the environment if exposed or
improperly handled or disposed off. It is estimated that approximately only 20% may be
considered hazardous where proper segregation is done.
Non hazards waste which constitute 80% does not pose much risk to human however, it can
cause a nuisances or create a breeding site of disease vectors like flies and rats if not properly
disposed

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The national guidelines for safe management of health care waste has the following categories.
1. INFECTIOUS WASTE:- This kind of category of waste is suspected to contain pathogenic
microorganism. It includes:
 cultures and stocks of infectious agents from laboratory work
 Waste fro surgery and autopsies on patients with infectious diseases e.g tissues,or
material that have been contact with blood or other body fluids
 Waste from patients in isolation wards (e.g excreta,dressing from infected or surgical
wounds,clothes soiled with human blood or other body fluids.
 Waste that has been contact with patients undergoing hemodialysis e.g dialysis
equipment such as tubing and filters,disposable towels,gowns,aprons,gloves and lab
coats among others
 Any other instruments or materials including food remains that have in contact with
infected persons or animals e.g HIV/AIDS,Diabetes home based care and IV DRUG
USERS.
2. PATHOLOGICAL WASTE:- This includes tissues,organs,body parts,human fortunes and animal
carcasses and body fluids
3. SHARPS:- Sharps are items that can cause cuts or puncture skin,and ,and may include
needles, hypodermic needles,scalpels,and other blades,knives,infusion sets saws,broken glass
and nails among others. They are highly hazardous.
4. PHARMACEUTICAL WASTE:- Pharmaceutical waste include expired spirit,and contaminated
pharmaceutical products. They also include drugs, vaccines and sera that are no longer needed.
It may also include those discarded items used in the handling of pharmaceutical, such as
bottles or boxes with residues and drug vials
MANAGEMENT AND DISPOSAL OF PHARMACEUTICAL WASTE
Sound management of pharmaceutical products facilitates waste minimization and it is of prime
importance to better waste management in general. Disposal of small amounts of chemical or
pharmaceutical waste is easy and relatively cheap; large amounts require the use of special
treatment facilities.
The disposal options for small quantities of pharmaceutical waste include those outlined in the
paragraphs below:
 Land fill:-Small quantities of pharmaceutical waste produced on a daily basis may
be land filled provided that they are dispersed in general waste. Cytotoxic and
narcotic drugs should not be land filled.
 Encapsulation:-small quantities of pharmaceutical waste may be encapsulated with
sharps where appropriate.
 Safe burial in hospital compound:- Safe burials of small quantities of
pharmaceutical waste prevents scavenging and attention should be paid to protect
ground water.
 Discharge to a sewer:- moderate quantities of relatively mild liquid or semi liquid
pharmaceutical,such as solutions containing vitamins,cow syrups,IV SOLUTIONS,or
eye or ENT drugs may be diluted in water and discharged in municipal sewer.
 Incineration:- small quantities of pharmaceutical waste may be incinerated
together with infectious or general waste, provided that they do not form more
than 1% of the total waste so as to limit potentially toxic emissions to the air.

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5. RADIO-ACTIVE WASTE:- Include solid,liquid and gaseous materials which are contaminated
with radionuclide. It is produced as a result of procedures such as India-vitro analysis of body
tissues and fluids,in vivi organs imaging and tumor localization, and various investigative and
therapeutic practices. Additional,the waste is also produced from health care research activities
radio-nuclide, and related activities such as equipment maintenance and storage
6. GENOTOXIC/CYTOTOXIC WASTE:- May include certain cytotoxic drugs ,chemicals and
radioactive materials. Genotoxic waste is highly and carcinogenic properties. It raises serious
safety problems,both inside hospitals and after disposal and should be given special attention.
7. CHEMICAL WASTES:- Consists of discarded solid,liquid,and gaseous chemicals, for example
from diagnostic and experimental work and from cleaning,house keeping and disinfecting
procedures. Chemical waste from health care may be hazardous or non-hazardous. In the
context of protecting health ,it is considered to be hazardous if it is
toxic,corrosive,flammable,reactive and or genotoxic.
8. WASTE WITH HEAVY METAL CONTENT:- This category include waste containing :-
 Mercury-mercury wastes are typically generated by spillage from broken clinical
equipment,residues from dentistry procedures and fluorescent tubes.
 cadmium- Comes from discarded batteries.
 lead :-leaded oils and paints and drugs containing arsenic among others

9.Non- infectious waste:-Waste generated from offices,kitchens,packaging materials and from

stores. It is similar to domestic waste.
PRINCIPLES OF HEALTH CARE WASTE
The general principles to be followed for the healthcare waste management are:
 The duty of care principle:- stipulates that any person handling or managing hazardous
substances or related equipment is ethically responsible for using the utmost care in
that task.
 The proximity principle:- It recommends that treatment and disposal of waste should
place at the closest possible locations to its source in order to minimize risks linked to
the transport of waste.
 The polluter pays principle:-it implies that all producers of waste are responsible for the
safe and environmentally sound disposal of the waste they produce.

KEY STEPS IN HEALTH CARE WASTE MANAGEMENT

1. MINIMIZATION:- Refers to approaches adopted by the health care facility to reduce the
amount of HCW generated during delivery of service. It includes strategies to reduce
unnecessary injections,recycling or re-using some of the materials.
2. SEGREGATION :-placing health care waste into separate at containers according to type of
category.
3. HANDLING AND STORAGE:-This refers to an organized system for removing waste from the
point of generation of temporary storage to a treatment or disposal site. Waste may be
transported within health facility or to an offsite treatment and disposal plants
4. TREATMENT:- is a means of rendering HCW safe handling and final disposal. Some of the
methods used include:-
 Incineration: burning at high temperatures over 600 degrees in an incinerator

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  Sterilization: using an autoclave.
 Chemical disinfection: treatment methods using chemicals such Jim render the
waste safe.
 Shredding using chemical grinders to minimize the waste

5.DISPOSAL:- by burying
END

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