1.

Primary Health Care (PHC)

2.Maternal and Child Health
3.Planning and Evaluation of
Community Health Services
TOPICS TO BE COVERED
•PHC Concepts
•History of PHC
•Pillars
•ELEMENTS
•Principles of PHC
•Strategies
•Limitations/problems that affect our health care
systems
•Mitigation measures for PHC limitation
•Maternal and child health care
•Planning and evaluation of community Health
 PHC CONCEPTS
Definitions
In 1978, the Alma Ata international confe
rence on PHC defined primary health care a
s:
“... essential health care based on practical, scientifically soun
d and socially acceptable methods and technology, made uni
versally accessible to individuals and families in the communit
y through their full participation, and at a cost that the commu
nity and country can afford to maintain at every stage of their d
evelopment in the spirit of self-reliance and self-determinatio
n.” Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 3
 CONCEPT OF PHC
PHC – a shift of emphasis to the community
Addresses every fundamental essential and basic
needs of people
It does not depend on the services offered by the
Ministry, but also inputs from other sectors for
the basic needs

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 4
 History of PHC
Before 1978, globally, existing health services were
failing to provide quality health care to the people.
Different alternatives and ideas failed to establish a
well-functioning health care system.
Considering these issues, a joint WHO-UNICEF
international conference was held in 1978 in Alma
Ata (USSR), commonly known as Alma-Ata
conference.
The conference included participation from
government from 134 countries and other different
agencies.
The conference jointly called for a revolutionary
approach to the health care.
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 5
 History of PHC
The conference declared ‘The existing gross
inequality in the health status of people particularly
between developed and developing countries as well
as within countries is politically, socially and
economically unacceptable’.
Thus, the Alma-Ata conference called
for acceptance of WHO goal of ‘Health for All’ by
2000 AD.
Furthermore, it proclaimed Primary Health Care
(PHC) as a way to achieve ‘Health for All’.
In this way, the concept of Primary Health Care
(PHC) came into existence globally in 1978
from the Alma-Ata Conference.
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 6
 Objectives of PHC
To increase the programs and services that
affect the healthy growth and development of
children and youth.
To boost participation of the community with
government and community sectors to improve
the health of their community.
To develop community satisfaction with the
primary health care system.
To support and advocate for healthy public policy
within all sectors and levels of government.
To support and encourage the implementation of
provincial public health policies and direction.
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 7

4 Pillars of Primary Health Care
Community Participation
– Active community
engagement
Inter-sectoral
Coordination – sectors
such as agriculture, sports,
education, and
administration among
others.
Appropriate Technology
– the right equipment and
modern procedures.
Support Mechanism
Made Available – political
goodwill Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 8
The Basic Requirements for Sound PHC
(the 8 A’s and the 3 C’s)
Appropriateness Assessability
Availability Accountability
Adequacy Completeness
Accessibility Comprehensiven
Acceptability ess
Affordability Continuity

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 9
1. Appropriateness:
Whether the service is needed at all in relation
to essential human needs, priorities and policies.
The service has to be properly selected and
carried out by trained personnel in the proper
way.
2. Adequacy:
The service proportionate to requirement.
Sufficient volume of care to meet the need and
demand of a community
3. Affordability:
The cost shouldPhilipbe
Mutua, within
+254701601551)
the means and
BSc|MSc|CPHO (Tel.
10
4. Accessibility:
Reachable, convenient services
Geographic, economic, cultural accessibility
5. Acceptability:
Acceptability of care depends on a variety of factors,
including satisfactory communication between health care
providers and the patients, whether the patients trust this
care, and whether the patients believe in the confidentiality
and privacy of information shared with the providers.
6. Availability: means that care can be obtained whenever
people need it.
7. Assessability: means that medical care can be readily
evaluated.

Philip Mutua, BSc|MSc|CPHO (Tel.

 +254701601551) 11
8. Accountability:
Accountability implies the feasibility of regular review
of financial records by certified public accountants.
9. Completeness:
Completeness of care requires adequate attention to
all aspects of a medical problem, including prevention,
early detection, diagnosis, treatment, follow up
measures, and rehabilitation.
10. Comprehensiveness
Comprehensiveness of care means that care is
provided for all types of health problems.
11. Continuity
Continuity of care requires that the management of a
patient’s care over time be coordinated among
Philip Mutua, BSc|MSc|CPHO (Tel.
providers. +254701601551) 12
PRINCIPLES OF PHC
1. Social economic development: Every
individual has a right to a quality of life. It must
have the purchasing power to buy those
essential commodities that contribute to the
quality of life
2. Self-reliance: Every individual has a right to
adequate information, appropriate skills to
utilize resources available to them without
relying on external or foreign resources
3. Equity and social justice: Resources available
to a country must be equitably distributed to its
population to meet their fundamental and basic
needs
4. Participation: People’s involvement (in
planning and implementation of programs)
5. Intersectoral Coordination: Nation-wide
coverage/wider coverage and coordination 13
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551)
 STRATEGIES OF PHC
A. USE OF APPROPRIATE TECHNOLOGY
 Not use of “low”
 Acceptable technology
 Health care needs of the population
 Capital and recurrent costs linked to
sustainability

B. HEALTH PROMOTION AND PREVENTION

 This principle acknowledges that the health
problems of developing countries are behavior
related
 Greater attention has to be paid to prevent
and promote activities which would exist
alongside the curative services
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 14
C. COMMUNITY PARTICIPATION
 Communities must be involved in the

implementation
 Participation in decision making

 Setting of health priorities

 Bottom-up decisions  Community Based

Strategy

D. INTERSECTORAL COLLABORATION AND

CO-ORDINATION
 Many determinants of health including food
production, housing, safe water, education
etc. All these require different actors and
providers
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 15
E. RE-ORIENTATION OF HEALTH
SERVICES
 Training of health workers and other sectors
towards PHC
 Integrating prevention, promotive and
curative aspects in health professional
training

F. USE OF LOCALLY AVAILABLE

RESOURCES
 Resources appropriate and acceptable to
local community
 Enhances sustainability in the absence of
external support
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 16
 ELEMENTS OF PHC
Nine (9) Minimum Packages
E = Education: IEC for behaviour change
L = Prevention and control of locally endemic
ailments)
E = EPI
M = Maternal and Child Health Care including
Family Planning
(FP)
E = Essential drugs (supply)
N = Nutrition and food supply (promotion of food
supply and
proper nutrition)
T = Treatment (Appropriate treatment of
common/minor diseases)
S = Sanitation and water (An adequate supply of safe
water and basic sanitation Kenya added these
element:
 Mental health
Because they are
 Community based rehabilitation endemic has already
 Dental health developed policies and a
 HIV/AIDS, Tuberclosis and Malaria
Philip Mutua, BSc|MSc|CPHO (Tel.
comprehensive service
 Ophthalmology (eye care)
+254701601551) 17
KEPH LEVELS OF CARE
KEPH-Kenya Essential Package for Health.
The levels of care include:
Level 1 - community
Level 2 - dispensary
Level 3 - health centres
Level 4 - district hospitals
Level 5 - provincial hospitals
Level 6 - referral hospitals

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 18
The Primary Health Care Program
Primary health care enables health systems to support a
person’s health needs – from health promotion to disease
prevention, treatment, rehabilitation, palliative care and
more.
This strategy also ensures that health care is delivered in a
way that is centered on people’s needs and respects their
preferences.
It includes the following levels of care/prevention:
Primordial and primary prevention: while primordial
prevention aims at reducing the risk, primary prevention
consists of measures aimed at a susceptible population or
individual to prevent disease from occurring.
Secondary prevention: aims to reduce the impact of a
disease or injury that has already occurred.
Tertiary prevention: aims to soften the impact of an
ongoing illnessPhilip
orMutua,
injury that(Tel.has lasting effects.
BSc|MSc|CPHO
+254701601551) 19
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 20
Organisation of Healthcare in the Devolved (County) System

• In the devolved system, healthcare is organized in a four-

tier system

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 21
 TIERS of Care
TIER 1:
– Community level i.e. offers CH services
– Its serves the local community of around 5,000 (1000 h
ouseholds)
– Services are provided by CHVs, CHAs (formerly CHEW),
CHC members
– Comprises of all community-based demand creation a
ctivities, that is, the identification of cases that need to b
e managed at higher levels of care, as defined by the h
ealth sector. Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 22
 TIER 2
• Includes;
– Dispensaries
– Health centres
– Maternity homes for both public and privat
e sector
– Majorly offers primary care services

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 23
 TIER 3
• These are hospitals operating in, and managed by
a given county and are comprised of the former
level four and district hospitals in the county and
include public and private facilities.

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 24
 TIER 4
• This level is comprised of facilities that provide
highly specialised services and includes all tertiary r
eferral facilities such KNH, MTRH, JOOTRH, KTRH,
MMH, NWH, MDH
• The counties are responsible for three levels of care:
community health services, primary care services
and county referral services.
• The national government has responsibility for
national referral services.
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 25
CURRENT STRATEGIES OF PHC IN KENYA
G – Growth monitoring
O – Oral rehydration
B – Breastfeeding
I – Immunization
F – Female education and
empowerment
F – Food security
F – Family planning
C – Community strategy
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 26
 Why is PHC Important?
PHC focuses more on quality health service
and cost-effectiveness.
PHC focuses on “Health for all”
PHC integrates preventive, promotive,
curative, rehabilitative and palliative
health care services.
PHC encourages new connection and
community participation.
It includes services that are readily accessible
and available to the community.
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 27
 Why is PHC important?
PHC can be easily accessible by all as it includes
services that are simple and efficient with
respect to cost, techniques and organization.
It promotes equity and equality.
It improves safety, performance, and
accountability.
It advocates on health promotion and focuses on
prevention, screening and early intervention of
health disparities.
It is also perceived as an integral part of
country’s socio-economic development.
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 28
 LIMITATIONS/PROBLEMS AFFECTING OUR
HEALTH CARE SYSTEMS
1. Illiteracy and ignorance
 Issues of health education and promotion
 Lack of participation in planning, management
2. Poverty
3. Misuse of funds allocated for health care
services
4. Mismanagement of the health care
facilities, equipment, materials
(resources)
5. Rampant corruption
 Drugs
 Equipment
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 29
 Construction
LIMITATIONS/PROBLEMS AFFECTING OUR
HEALTH CARE SYSTEM…Cont’d
6. Inadequate funding from the
Government and health care partners
7. Inadequate staffing – personnel
8. Lack of motivation of staff
9. Lack of re-training of staff
10. Political interference or goodwill
11. Political instability and poor leadership
12. No monitoring and evaluation
13. Technological conflict (high Vs.
Philip Mutua, BSc|MSc|CPHO (Tel.

inappropriate)
+254701601551) 30
LIMITATIONS/PROBLEMS AFFECTING OUR
HEALTH CARE SYSTEM…Cont’d
14. Women and community empowerment
(discrimination)
15. Poor policies (do not involve the people)
16. Insecurity (people, food etc.)
17. Top-down and bottom-up approaches
conflict

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 31
 What are the Mitigation Measures for
Ensuring Effective PHC?
Encouraging community participation through
rapport building, effective communication and
sharing objectives and benefits of PHC.
Developing quality assurance mechanisms
through the development of various indicators
and standards.
Development of clinical guidelines including
the implementation of Essential drugs list
Allocating resources as per the need of the
central, provincial/state and local level.
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 32
 What are the Mitigation Measures for
Ensuring Effective PHC?
Develop a planning process to define objectives and set
targets by giving priority on those families and
communities most at risk.
Promoting problem-orientated research in health
management system.
Creating pathways to give health higher priority on the
agenda of district development and collaboration of
health departments to perform its role in health
activities.
Develop guidelines and framework that specify the
roles and responsibilities of the provincial states.
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 33
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 34
 INTRODUCTION
Maternal and child health
Definition:
 Maternal and child health (MCH) refers to the health
of mothers, infants, children, and adolescents.
 MCH refers to the promotive, preventive, curative,
and rehabilative health care for mothers and
children.
 It also refers to a profession within public health
committed to promoting the health status and future
challenges of this vulnerable population (Breslow,
2002)
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 35
JUSTIFICATION FOR MCH SERVICES
Maternal and child health has received
considerable attention from almost all nations.
The health of women and children tend to an
indicator of developmental level of a country.

Why the need for maternal and health services:

1. Mothers and children constitute over 60% of the
whole population. Child bearing women in
developing countries make up about 21% of the
population. Pregnant women 4.5%, children under
15 years 47%.Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 36
3. Most pregnant women in the developing world do
not attend the required number of antenatal visits
and this means that they do not receive the
comprehensive antenatal care package necessary
for a healthy pregnancy outcome.
4. Most health facilities in developing countries do
not have adequate resources needed to address the
needs of the mother and child. As such, most women
deliver without the help of a trained health care
provider, risking their lives and those of their
babies.

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 37
5. A number of unwanted pregnancies end up in
unsafe abortions thus threatening the lives of the
women particularly those who do no have access to
comprehensive reproductive health services.

6. Women play a number of roles in the community

and most of the time they tend to forget about their
own health as they concentrate on tending for others.
This predisposes them to a number of negative effects
including poor nutrition which in turn impacts on the
health status of the unborn.
Philip Mutua, BSc|MSc|CPHO (Tel. +254701601551) 38
7. Poor maternal health affects a woman’s productivity,
their families welfare and socio-economic development.
8. Infectious diseases like malaria tend to be more
prevalent in pregnant women. If untreated, they can
influence pregnancy outcome like low birth weight
babies.
9. Poor maternal nutritional status may result also in a
low birth weight baby
10. Large number of women are suffering from chronic
illnesses that can be exacerbated by pregnancy and
child bearing.
11. An increasing number of women are testing HIV
positive and there is risk of mother to child HIV
transmission. Without any intervention, the risk of
Philip Mutua, BSc|MSc|CPHO (Tel.
MTCT is between 25-40%.
+254701601551) 39
12. Some women who were otherwise normal before
a pregnancy have suffered disability due to
pregnancy related complications like uterine
prolapse, vesico-vaginal fistula and the related urine
incontinence.
13. Majority of perinatal deaths are associated with
maternal complications, poor management
techniques during labour and delivery

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 40
14. Fetal and perinatal death are likely to follow a
maternal death. Less than 10% of infants who survive a
maternal death live beyond their first birthday.
15. Poor delivery techniques and poor management
during labour can lead to developmental impairments
among children.
16. Women often lack access to relevant information,
trained providers and supplies, emergency transport,
and other essential services.
17. Many women tend to have a heavy workload despite
their low food intake. Moreover, they marry early,
spending most of their lifespan in pregnancy and
lactation- activities requiring high energy expenditure.
This predisposesPhilip
mothers to deliver low birth weight
Mutua, BSc|MSc|CPHO (Tel.
infants. +254701601551) 41
18. Cultural attitudes and practices impede women's
use of services that are available.
19. Children whose earliest years are faced by
hunger or disease or whose minds are not stimulated
by appropriate interaction with adults and their
environment will experience grave and negative
consequence throughout their lives-and so does
society as they would be less contributory member.
(Addisse, 2003)
20. Perinatal deaths have been associated with
antepartum haemorrhage, eclampsia and other
pregnancy complications. These conditions have also
been linked to poor growth and development of
Philip Mutua, BSc|MSc|CPHO (Tel.
infants who survive.
+254701601551) 42
 LIFE COURSE THEORY
A life course is defined as ‘ a sequence of socially
defined events and roles that the individual enacts
over time’.(wikipedia).
Aka: life course perspective, life course theory.
The life course approach examines an individual’s
life history and looks at how early events influence
future decisions and events such as marriage,
divorce, engagement in crime and disease
incidence.
It examines the connection between individuals’
lives and the historical and socio-economic context
in which these lives unfold.
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 43
 The Life Course of Unwed Motherhood
Premarital sexual experience
among young, never-married females Non experience

Sex without contraceptives Contraceptive protection

Pregnancy Not Pregnant

Decision to have child out of wedlock Abortion or marriage

Decision not to marry after birth Marriage following birth

Unwed motherhood

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 44
Immediate Causes of maternal deaths worldwide

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 45
 Causes of maternal mortality in
Kenya
Direct causes: causes resulting from
pregnancy and delivery complications:Hemorrhage
(APH and PPH),Sepsis, Pre-eclampsia and
eclampsia,Ruptured uterus and Complications of induced
abortion
Indirect causes: causes not directly related to
pregnancy and delivery but are exacerbating
factors. Eg malaria, anaemia, HIV, TB,

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 46
Direct Causes of Maternal Mortality, 2003-2005
Obstracted labour
Abortion/miscarriage
6% 17%
Obstructed labour 6%
Uterine rupture Abortion/misscarriage Antepartumhaemorrhage
Antepartum hemorrhage
3% Rupture 6%
17% 6%
3%

Pueperal sepsis Ecclampsia

Puerperal sepsis 28%
28% 6% Eclampsia 6%

Other
Otherscomplications
complications
preg,postp & delivery
Pre, postpartum and delivery
Postpartum hemorrhage 14%
Postpartum 14%
haemorrhage14%
14% Others
Others 6%
6%

CDC: Ofware
Indirect causes of maternal mortality

Respiratory diseases
11% Anaemia
Pulmonary TB 11%
9%

HIV/AIDS/AIDS related
conditions (ARC)
40%
Others
17%

Malaria
13%

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 48
MATERNAL HEALTH SERVICES
Focused Antenatal care (FANC)
Malaria in pregnancy
Prevention of mother to child HIV
transmission
Delivery care services
Postnatal care services
Family planning services

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 49
 SAFE MOTHERHOOD +

CARE

TARGETED POSTPARTUM

POST ABORTION CARE

CARE
ESSENTIAL OBSTETRIC
NEONATAL CARE
CARE
FOCUSED ANTENATAL
CARE
PRE –CONCEPTION
FAMILY PLANNING &

DELIVERY
CLEAN AND SAFE
TRANSMISSION
MOTHER TO CHILD
PREVENTION OF
SKILLED ATTENDANTS AND ENABLING ENVIRONMENT TO PROVIDE QUALITY
CARE

SUPPORTIVE HEALTH SYSTEMS

EFFECTIVE SYSTEMS OF REFERRAL, MANAGEMENT, PROCUREMENT,
TRAINING, SUPERVISION, AND HEALTH MANAGEMENT INFORMATION SYSTEM

COMMUNITY ACTION, PARTNERSHIPS, MALE INVOLVEMENT

EQUITY FOR ALL /REPRODUCTIVE RIGHTS

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 50
 Focused Antenatal care
(FANC)
What is FANC?
It is personalised care provided to a pregnant
woman which emphasises on the woman’s overall
health, her preparation for childbirth and readiness
for complications (emergency preparedness).

 It is timely, friendly, simple and safe service to a

pregnant woman.

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 51
AIM OF FANC

To achieve a good outcome for the mother and

baby and prevent any complications that may
occur in pregnancy, labour, delivery and post
partum

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 52
 1st visit: <16 weeks

2nd visit: 16-28 weeks

3rd visit: 28-32 weeks

4th visit: 32-40 weeks

Objectives of Focused Antenatal
Care
Early detection and treatment of
problems
 Prevention of complications using safe,
simple and cost-effective interventions
Birth preparedness and complication
readiness
Health promotion using health messages
and counseling
Provision of care by a skilled attendant

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 54
 Objective one: Early detection and treatment of
Problems
Service providers should identify existing medical, surgical or
obstetric conditions during pregnancy. Such as:
– Severe anaemia (Hb <7gm/dl)
– Vaginal bleeding
– Pre-eclampsia (increased BP, severe oedema)
– STI’s, HIV/AIDS, TB and Malaria
– Chronic diseases (diabetes, heart or kidney problems)
– Decreased/absent foetal movement;
– foetal malpresentation after 36 weeks

Philip Mutua, BSc|MSc|CPHO (Tel. +254701601551) 55

Objective two: Prevention of complications
The service provider should ensure
prevention/protection of complications by providing:
Tetanus toxoid to prevent maternal and neonatal
tetanus
Iron/folate supplementation to prevent anaemia
Use of IPT and ITNS to prevent malaria/ anaemia
Ensure environmental hygiene to prevent intestinal
worms
 Presumptive treatment of hookworm infection with
Mebendazole 500mg STAT anytime after the first
trimester*

Philip Mutua, BSc|MSc|CPHO (Tel. +254701601551) 56

 Objective three: Birth preparedness and
complication readiness
Service providers should discuss components of
birth plan which include:
Place of birth
Skilled attendant
Transportation
Funds
Birth companion
Items for clean and safe birth and for newborn

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 57
Objective three cont…Complication Readiness
Knowledge of danger signs; what to do if they arise
Choose decision maker
Emergency funds
Emergency transport
Blood donor

Philip Mutua, BSc|MSc|CPHO (Tel. +254701601551) 58

 Discuss birth partners/companions with your clients
A birth partner/companion may be the father of the baby,
a sister, a mother-in-law, mother or an auntie.
A birth partner/companion should be involved in making
the individual birth plan (IBP).
A birth partner/companion can provide support to the
woman during pregnancy at the antenatal clinic and during
delivery.
Make sure clients at your clinic know that you welcome
birth partners/ companions

Philip Mutua, BSc|MSc|CPHO (Tel. +254701601551) 59

 Individual birth plan ensures that the client:
Knows when her baby is due
Identifies a skilled birth attendant
Identifies a health facility for delivery/emergency
Can list danger signs in pregnancy and delivery and
knows what to do if they occur
Identifies a decision-maker in case of emergency
Knows how to get money in case of emergency
Has a transport plan in case of emergency
Has a birth partner/companion for the birth
Has collected the basic supplies for the birth

Philip Mutua, BSc|MSc|CPHO (Tel. +254701601551) 60

 Danger signs in pregnancy
Any vaginal bleeding in pregnancy( APH, Abortion)
Severe headache or blurred vision (high blood pressure,
eclampsia)
Swelling on the face and hands (high blood pressure,
eclampsia)
Convulsions or fits (high blood pressure, eclampsia)
High fever ( infection)
Laboured breathing ( pneumonia, heart problems, severe
anemia)
Premature labour pains
Noticed that the baby is moving less or not moving at all
(fetal distress).

Philip Mutua, BSc|MSc|CPHO (Tel. +254701601551) 61

 Other danger signs in pregnancy
Feeling very weak or tired (anemia, severe disease,
multiple pregnancy)
Vaginal discharge (STI)
Abdominal pain (STI, early labor)
Genital ulcers (STI)
Painful urination (STI)
Persistent vomiting( severe malaria etc)

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 62
 Danger signs during labour and delivery
Severe headache/visual disturbances
Severe abdominal pain
Convulsions or fits during labour
High fever with or without chills
Foul vaginal discharge
Labour pains for more than 12 hours
Ruptured membranes without labour for more than 12
hours
Excessive bleeding during delivery
Cord, arm or leg prolapse

Philip Mutua, BSc|MSc|CPHO (Tel. +254701601551) 63

 Danger signs after delivery
Placenta not delivered within 30 minutes of baby’s birth
Excessive bleeding after delivery
Severe abdominal pain
Convulsions or fits
High fever with or without chills
Foul vaginal discharge due to infections
Mood swings (depression)
 Family members and skilled birth attendants should
know the danger signs of life-threatening
complications and what to do
 Often the decision to seek care and arrange for transport
is delayed as much as 1-3 days after recognition of a
life -threatening complication.
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 64
Recognize danger signs and get prompt medical attention!
Acting quickly is important because a woman could die in a
short period of time:
 in antepartum hemorrhage she can die in just 12 hours.
 in postpartum hemorrhage she can die in just 2 hours.
 with complications of eclampsia in as few as 12 hours
and
 with sepsis in about 3 days!

Philip Mutua, BSc|MSc|CPHO (Tel. +254701601551) 65

 Objective four: Health education & promotion using
health messages and counseling

Encourage dialogue on the following:

Nutrition Drug compliance

Rest and hygiene Family planning/ health
Safer sex timing and spacing of
pregnancy
Care for common Early and exclusive
discomforts Breastfeeding
Use of IPT and ITNs/LLINs Newborn care

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 66
 Maintain the woman’s health and survival through:
Health education and counselling on:
Danger signs in pregnancy
Adequate nutrition and hydration
Early and exclusive breastfeeding
Prevention and treatment of sexually transmitted
infections (STIs) and worm infestation
Avoidance of alcohol and tobacco
Individual Birth Plan (IBP)
Complication readiness plan
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 67
 Don’t forget to counsel the mother on…
To come to postpartum clinic : Immediately, 48hours, 2
weeks, at 6 weeks,6months and one year.
To visit well baby clinic (MCH/FP Clinic) for immunizations
Follow up for exposed babies to TB and HIV.
To chose a postpartum family planning method:
– LAM (exclusive breastfeeding)
– Progesterone only pills
– Condoms
– Post partum IUCD
Feeding options

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 68
 Teach mothers about the importance of
immunizations:
Inform her about the first-year immunization schedule
to protect children from TB, polio, tetanus, diphtheria,
pertussis, hepatitis B and measles.

Immunize baby with BCG, HBV, OPV, PCV birth dose

before the mother leaves the health facility.

Ensure all babies delivered at home are taken to the

health facility for immunization.

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 69
 NATIONAL IMMUNIZATION SCHEDULE
Kenya
Recommended routine immunization
Vaccine Description Schedule Comments
Primary Infant and Adolescent Vaccination Schedule
BCG Bacille Calmette-Guérin vaccine Birth
OPV Oral polio vaccine Birth; 6, 10, 14 weeks
Rotavirus Rotavirus vaccine 6, 10 weeks

Pneumo_conj Pneumococcal conjugate vaccine 6, 10, 14 weeks

Diphtheria and Tetanus and
DTwPHibHep Pertussis and Haemophilus 6, 10, 14 weeks
B influenzae and Hepatitis B vaccine
IPV Inactivated polio vaccine 14 weeks

YF Yellow fever vaccine 9 months Not available in all parts of the

country
Measles Measles vaccine 9, 18 months

HPV Human Papillomavirus vaccine 10 years; +6 months From january 2018

Adult Vaccination Schedule
High risk groups (e.g. health
HepB_Adult Hepatitis B adult dose vaccine 1st contact; +1, +1 workers)
months
TT Tetanus toxoid vaccine 1st contact pregnancy; +1, +6
months; +1, +1 year
Vaccines for Travellers
70
st
 Objective 5: Provision of Skilled Care at Birth
A skilled attendant offers services either at the health
facility or within the community
FANC provides an opportunity to increase skilled care

Philip Mutua, BSc|MSc|CPHO (Tel. +254701601551) 71

 The role of men/fathers should be to:
Support and encourage women throughout pregnancy
Ensure that mothers do not get STIs (or HIV)
Ensure that they remain faithful (or use condoms
consistently and correctly)
Encourage mothers to attend antenatal clinic
Accompany their wives/partners to the health facility and
during childbirth

Philip Mutua, BSc|MSc|CPHO (Tel. +254701601551) 72

 Service providers should educate fathers about
antenatal care
Fathers should make sure that the woman:
– has enough nutritious food to eat and that she has
taken iron and folate tablets.
– is sleeping under a treated net and is able to get
plenty of rest.
– has had 2 doses of SP and tetanus toxoid.
Make sure that the couple has an individual birth plan.

Make sure that the couple know the danger signs in

pregnancy and labour.
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 73
Brainstorm
 What are the attitudes of service providers about
providing antenatal care to adolescents in your
clinic?
 Why do providers treat adolescents differently?
 Does your clinic provide antenatal services to
adolescents?
 Are the services in your clinic youth-friendly?
 How can HCP change their attitudes about
providing care for adolescents?
 Integrated FANC Services
FANC TB

STIs PMTCT

LAB CCC
MALARIA

Philip Mutua, BSc|MSc|CPHO (Tel. +254701601551) 75

Community Based Maternal and Child Health
Care (CBMCHC)
The concept of community-based maternal and
newborn care is more relevant in relation to
community-based care interventions.t
These services are important for reducing neonatal
mortality rates.
Community-based maternal and newborn care is
viewed as a good program for improving newborn
survival.

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 76
 Community Based Maternal and Child Health
Care (CBMCHC)
Community-based care is the provision of skilled
therapy services within a client’s own home or
community, with the requirement that the
practitioner take into consideration the lifestyle of
the client and the cultural and social characteristics
of the client’s community.
Community-based care views the community in the
following models:
 community as setting,
 community as target,
 community as resource and
Philip Mutua, BSc|MSc|CPHO (Tel.
 community as agent.+254701601551) 77
 1. Community as a setting for interventions
In maternal and newborn care, the setting plays a
crucial role.
There is a need to understand the population that
needs to change in community-based care as a setting
in order to reduce maternal and newborn deaths by
using SBAs who are well trained and who understand
maternal and newborn care services in the
communities.
This community-based care consists of assessing,
planning and managing maternal and newborn
care services as well as referral systems in
response to complications
Community-based care will help SBAs to identify
complications early, ensuring that mothers and babies
are cared for properly within(Tel.their community
Philip Mutua, BSc|MSc|CPHO
+254701601551) 78
 2. Community as a Target
Community indicator projects use data as a catalytic
tool to go beyond the use of individual behaviors as
primary outcomes.
 In the case of maternal and newborn health, changes
can be initiated positively within the community in
order to reduce maternal and neonatal mortality
3. Community as resource:
The model is mostly used in community-based health
promotion services in order to enhance community
ownership and participation as essential elements for
sustained success in population health outcomes
In maternal and newborn care, this model can be applied
by providing community members, SBAs and pregnant
women or women who have just given birth with
information regarding maternal and newborn services
available in their communities. 79
 4. Community as agent.
Although closely linked to the model of community
as a resource, the emphasis in this model is on
respecting and reinforcing the natural adaptive,
supportive and developmental capacities of
communities.

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 80
 Attributes of CBMCHC
 Provision of home- and/or community-level
skilled care:
 Interventions are available where and when they are
most needed to significantly save lives in that maternal
and newborn care is provided in communities using
available resources, which is cost-effective.
 Linkages of health services:
 Women and their newborns must receive lifesaving
care as soon as complications happen, during referral
and at appropriately equipped health facilities.
 These connections must be established, maintained,
evaluated and redesigned over time as the situation
changes.
Philip Mutua, BSc|MSc|CPHO (Tel. +254701601551) 81
 Attributes…
 Community participation and mobilization:
 Community members assess their own health needs
and develop and monitor their own solutions to
identified problems.
 Community-based care normally coincides with a
high degree of community participation because the
onus is on communities to care for their own in
addressing the problems at hand.
 This is also applicable in respect of maternal and
newborn care services, where community members
can be involved in helping each other regarding
these services and identifying SBAs in their
communities.
 Finally, CBMCHC comes in to solve the 3 delays in
maternal healthPhilip care (which
Mutua, BSc|MSc|CPHO
+254701601551)
(Tel. cause maternal death)
82
 Three delays and right to health
Three delays Corresponding right to
health entitlements and
freedoms
1.Delay in seeking •Access to health information and
appropriate medical help for education
an obstetric emergency for • Access to affordable and
reasons of cost, lack of physically accessible
recognition of an emergency, •health care Enjoyment of the
poor education, lack of access to right to health on the basis of non-
information and gender discrimination and equality
inequality.
2. Delay in reaching an Safe physical access to health
appropriate facility care
for reasons of distance,
infrastructure and transport
3. Delay in receiving •An adequate number of health
adequate care when a facility professionals
is reached because there are • Availability of essential 83
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 84
 Introduction
Community Health Planning - a systematic
process of identifying the health needs of
communities and developing evidence-based
recommendations and strategies to promote and
improve the health of individuals and communities.
The goal of planned approach to community
health services is to increase the capacity of
communities to plan, implement, and evaluate
comprehensive, community-based health programs
targeted toward priority health problems.

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 85
Objectives of Planning Community Health services
Planned approach to community health helps in:
Systematic implementation of activities
Establishing a health working teams
Define key data to be collected and used
Set health priorities, and design and evaluate
interventions
Identify and address priority health problems or
special population to be addressed
It can also be adapted and used by existing
organizational and planning structures in the
community. Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 86
A planning cycle in the development of a
community health program
A planning cycle that includes:
A situation analysis,
Formulation of objectives,
Selection of strategies,
Development of an operational plan,
Implementation and evaluation, which
lead, in turn, to a new situation analysis.

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 87
 Choosing Health Priorities
Most communities do not have the resources to
address all of their health problems and target
groups at once.
They must set priorities and plan to address some
problems initially and others over time.
Communities are required to select only one or a
limited number of health problems to better focus
resources in a comprehensive manner.
Priority setting techniques:
1. Problem/Preference Ranking - participatory
technique that allows analyzing and identifying
problems or preferences stakeholder share in order
to implement adequate improvements and solutions
in their community and area.
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 88
First, the stakeholders have to decide which the most
important problems they face in their community are.
Afterwards, the participants have to rank these
problems/preferences in regards to their importance.
The result of this method provides the starting base
for discussions on possible solutions to the priority
problems.
2. Pairwise ranking (systematic method) and uses
cards to represent the different problems.
The facilitator shows the “problem cards”, two at a
time, each time asking, “Which is the bigger
problem?”
As the participants make the comparisons, the results
are recorded in Philipa matrix.
Mutua,
+254701601551)
BSc|MSc|CPHO (Tel.
89
Advantages
Preference/Problem ranking method helps to quickly
get a good idea of what people think are the priority
problem or preferences
Preference/Problem ranking is probably the easiest
method to use and to learn more about commonly
shared problems and priorities
The criteria developed out of the ranking can be
used for the community action plan of the area
Disadvantages
It requires time and some logistic efforts to bring all
relevant stakeholders together in order to rank the
preferences and problems
It may not be possible to react to all the problems
discussed Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 90
 Identifying which problem(s) to address first
When examining priority behavioral risk factors,
you might consider the following:
Importance - evidence that the behavior change will
make a difference eg.
 How widespread is the behavior?
 How serious are the health consequences?

 How close is the connection between the behavior and the

health problem?
Changeability - evidence that the behavior is
amenable to change e.g.
 Is the behavior still in developmental stages?
 Is the behavior only superficially tied to lifestyle?

 Has the behavior been successfully changed in other

programs?
 Does the literature suggest that the behavior can be
Philip Mutua, BSc|MSc|CPHO (Tel.
changed? +254701601551) 91
Some issues to consider when ranking problems
Legal and economic factors,
Political viability of the intervention,
Possibility of continued funding,
Probability of quick success,
Ability to build on community strengths,
Level of public concern

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 92
 Goal setting
Involves establishing specific, measurable,
achievable, realistic and time-targeted
(S.M.A.R.T ) goals.
Characteristics of a good goal:
Specific - When setting goals, they should answer the
highly specific questions of who, what, where, when, and
why.
Measurable - In order for us to track our progress, goals
should be quantifiable.
Attainable - It is important to evaluate your situation
honestly and recognize which goals are realistic, and
which are a little far-fetched.
Relevant - Is this goal relevant to your life? Does this
match my needs?
Time-related - Setting a "due date" to meet goals not
only keeps you on track, but it prevents pesky daily 93

Goals and Objectives
Goals are broad, abstract statements of intent that
help create a vision of what you are striving to
accomplish.
Objectives are measurable, specific statements that
lead toward program goals and define what change the
community will try to achieve.
The importance of both in anchoring the community
health-planning process cannot be emphasized enough,
for vague goals and objectives are likely to yield
scattered, unfocused efforts.
Community health planning uses two types of
objectives to clarify community goals:
Behavioral objectives- for the leading behaviors that
contribute to death or disability and are the focus of the
intervention
Intervention objectives - for(Tel.
Philip Mutua, BSc|MSc|CPHO the interventions you wish to
+254701601551) 94
Writing behavioral and intervention objectives
Behavioral objectives refer to those behavioral risk
factors that contribute to the cause of death
specified in your community goals.
The intervention objectives refer to the
intervention activities you plan to undertake.
The community goal is more general, the
behavioral objectives are more specific, and the
intervention objectives the most specific.
See footnotes for examples:

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 95
 Community health planning process
Step I: Mobilizing the community – Mobilizing
the community is an ongoing process.
The community organizes to begin planning and
continues throughout the process.
Here:
The community to be addressed is defined,
Participants are recruited from the community
Partnerships are formed
Demographic profile of the community is completed

Philip Mutua, BSc|MSc|CPHO (Tel.

+254701601551) 96
Step II: Collecting and organizing data: begins
when the community members form working groups
to obtain and analyze data on mortality, morbidity,
community opinion, and behaviors. These data,
obtained from various sources, include quantitative
data (e.g., vital statistics and survey) and qualitative
data (e.g., opinions of community leaders).
Step III: Choosing health priorities: During this
phase, objectives related to the health priorities are
set. The health priorities to be addressed initially are
selected.
Step IV: Developing a comprehensive
intervention plan: Using information generated
during steps II and III, the community group chooses,
designs, and conducts interventions
Philip Mutua, BSc|MSc|CPHO (Tel. during phase.
+254701601551) 97
Step V. Build on existing services: In order to
prevent duplication and to integrate the existing
services, the community group identifies and
assesses resources, policies, environmental
measures, and programs already focused on the risk
behavior and to the target group.
Step VI: Evaluating plans: Evaluation is an
integral part of the planning process.
It is ongoing and serves two purposes:
to monitor and assess progress during the five phases
of planning and
to evaluate interventions.
The community sets criteria for determining
success and identifies data(Tel.to be collected
Philip Mutua, BSc|MSc|CPHO
+254701601551) 98
 Detailed implementation plan
The analysis steps make it possible to draw a Project
Planning Matrix (PPM).
The PPM is a matrix of four columns and four rows
providing 18 squares for a comprehensive description of
a project.
PPM shows both the project's logical structure (the links
between the inputs/activities and the objectives to be
achieved under certain Assumptions), and its major
quantitative data (see example in the word
document).
The PPM is useful in two ways:
Showing activities t be carried out in their sequential order
Shows the type of activity to be done and by who
Shows what activities should be done in what time
Shows the budget needed for each activity 99
 Measures of success
The 4 essential key measures of success are:
Financial viability - Example: profitability.
Customer satisfaction - Example:
performance on customer satisfaction
surveys.
Employee satisfaction - Example:
performance on employee satisfaction
surveys.
Contribution to society - Example: number of
trees saved by developing paperless
processes. Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 100
Importance of Measures of Success
Financial viability measures organizational
survival and growth.
Customer satisfaction is important because
without happy customers the organization will fail.
Employee satisfaction is important because over
the long term it is impossible to have an
organization with unhappy employees that has
happy customers
Contribution to society (e.g., environment, ethics,
safety, social responsibility) is important because
every organization needs more than a simple profit
motive to attract and retain the best talent and to
sustain itself over time. An organization in which
greed is a core value will ultimately devour itself.
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 101

Outcome Evaluation
Outcome indicators – are long terms effects as a
result of the outputs.
Outcome evaluations examine the results of a
program (intended or unintended) to determine the
reasons why there are differences between the
outcomes and the program's stated goals and
objectives.
Outcome measurement is a systematic way to
assess the extent to which a program has achieved
its intended outcomes.
It helps understand whether the program is
effective or not.
See Example in Word Document
Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 102
 Reference and Further Reading
Guta YR, Risenga PR, Moleki MM, Alemu MT.
Community-based maternal and newborn care: A
concept analysis. Curationis. 2018 Sep 26;41(1):e1-
e6. doi: 10.4102/curationis.v41i1.1922. PMID:
30326707; PMCID: PMC6191673.
https://www.who.int/news-room/fact-sheets/
detail/primary-health-care
https://www.health.gov.nl.ca/health/
publications/
moving_forward_together_apple.pdf
https://www.open.edu/openlearncreate/mod/
oucontent/view.php?id=219&section=1.5.2
Philip Mutua, BSc|MSc|CPHO (Tel.
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Philip Mutua, BSc|MSc|CPHO (Tel.
+254701601551) 104