Case Study

Gandini Dispensary- monitoring services

Date(s): 15-02-2022

Region: Kwale County (Gandini village unit).

Issue:

• The nurse in charge was reporting late (sometimes at 11am) while patients were coming to the facility very early (from 7 am)
• There were always shortage of supplies and patients were being referred to a nearby shop to buy drugs.
• One of the supporting staff was being accused of peeping through the delivery room window whenever there is a woman giving birth.
• The DHC was being involved in budgeting and withdrawal of funds but left in the dark during procurement. Some of the supplies budgeted for and money withdrawn to facilitate the purchase could not be traced. For example the committee had budget and withdrew money for purchase of a television set which was never seen in the facility.

What was the problem?

Nurse In charge reporting late.
Most times patients would be found lying down at the waiting bay since the seats available cannot accommodate all the patients patiently waiting for the nurse to arrive. Emergency cases would not be handled during the night and early morning hours since the nurses do not stay near the facility. The staff house which was constructed through CDF funding over five years ago is considered unfit to live in. Despite his coming late, the services he provided were good according to the community. Some community members claimed that he was against living within the facility because he runs his own clinic and hence in the morning hours he would attend to his private patients at his home then come to the facility and if the patients were many then he would completely not avail himself to the facility

Shortage of supplies
The community had identified the shop where the nurse would send someone to drop the drugs. There was always shortage of drugs at the facility. Once drugs are ordered and brought to the facility, within few days the patients would be asked to buy drugs from the nearby shop.

The support staff peeping through the delivery room window.
It was noted that women are not comfortable to deliver in this facility. Only emergency cases would be rushed to the facility but most times women would plan to deliver in facilities of their choice. The in charge and the support staff were said to be good friends and therefore would not give a stern warning for the support staff to stop this habit. The support staff who is the watchman would assume nurse's role whenever the nurses were not in the facility i.e. at night and early morning hours.

Lack of transparency and accountability.
The nurse in charge would come up with needs-based budget and the DHC would only meet to rubberstamp them and not play a participatory role in the meeting. Again, the issue of the receipts failing to see the light of the day whenever they requested There is a time one of the monitors came across empty receipts the nurse in charge had misplaced and to them it implied that the receipts would be used to cook figures so as to balance the books . The in charge would provide list of items and other committee members would endorse. After all they do not understand or they cannot verify whether those supplies are necessary or not. Sometimes they would also agree on items to be procured and/or services to be provided by specific people only for the in charge either identify very different people to do the work without disclosing how much they have been paid or not to purchase or identify people to offer the services. At the end of the day, the in charge would send the reports to Kinango without the committee knowing the details of that report.

How was the problem identified?

When the VOICE project kicked off in October 2019, monitors were identified to monitor service delivery in various facilities. There was no a specific area of focus though DevCheck app provided a guideline on areas in which the monitors can provide feedback.

Even before training, the monitors had identified the issue of nurse in charge reporting late for work. This was an issue that community members were not happy about because they have to waste hours waiting for the nurse to arrive.

In one of their meetings, the monitors tried to analyse what could be the reason for him reporting late and what solutions could be there to address the problem. This is where they tried to engage the DHC so as to be able to understand in depth the root cause of this problem.

It took some time to engage and bringing the committee together since most time the in charge would work with the treasurer and chairperson of the committee who are the signatories to the facility account. This caused division amongst the committee members.

In 2020 when Covid-19 came, the restrictions imposed made it difficult for monitors to continue visiting the facility and conduct community surveys. However, the monitors had managed to bring together the committee members and had started analysing the problems.

From the engagements with the DHC, the other problems were identified. The committee shared more light about the accountability issues. The monitors informed KYGC on their engagements with the DHC and where they need to be supported in order to address the issues identified.

During a meeting that brought together DHC, monitors and KYGC, it was noted that the DHC do not clearly understand the strength they have in addressing the issues they are facing. Some were not sure on what their role is as a committee. We also noted the misconception that whenever one is a DHC, s/he is entitled to attend to the patients despite how sensitive the illness was.

Resolving the problem

After identifying the issues, a series of meetings were held to find and implement possible solutions.

The committee was tasked to write to and visits the sub county public health office to table their concerns. The DHCs demands were for the in charge to be transferred and refund funds that were withdrawn but not accounted for. For instance the funds that were meant to purchase the television set. Auditors/ department officers were sent to the facility for a fact finding mission.

KYGC linked the DHC with `Jicho Pevu`, a sub county health advocacy committee that operates within Kinango sub county. This was meant to serve as an alternative approach to solve the problem in case the health department does not act with speed.

The monitors under the Kinango Community Monitors CBO held a series of meetings with the community to discuss how the community can participate in ensuring transparency and accountability in the facility. The shop in which the drugs were being sold was being owned by one of the locals. The affected people are residents of Gandini and therefore if they do not speak out the issues will not be solved.

The auditors confirmed most of the allegations made towards the in nurse charge and He was sent on a compulsory leave after which he was transferred to a facility in one of the remote areas of Kinango Sub county. The DHC and community members are attending public participation forums to ensure some of their needs are address. For example they have made proposals for construction of staff house and maternity wing. These projects are in the pipeline while others have been approved and soon they construction will start.

Results

The community is happy at least a number of problems have been fixed. The DHC members are now free to seek treatment at the facility. The DHC now understands better their role in managing the facility. The remaining staffs at the facility are more alert since they have seen what their colleague went through. The nurse in charge was transferred to a remote area and his colleague is now in charge. The DHC confirmed that their working relationship with the new in charge is good and they get answers to all their questions.
During the end of VOICE project evaluation, one of the committee members narrated how she fronted the needs of the facility during a public participation forum and she was backed up by other community members who were present. This is as indication that the committee now understands what they can influence as a committee.

However, the facility now has a shortage of two staff since the support staff and the nurse were transferred and no replacement has been made. For instance during the final evaluation, the DHC pointed out that the facility was closed for about 3 weeks since the only nurse was sick and therefore not available to offer the services. The community though do not regret the course of action they took to bring the changes. To address this new problem, the DHC have written a letter to the public health office requesting for additional of more staff.

Quotes

“He said he cannot come early since he has to pass via Kinango to collect the drugs” said one of the monitors.

“I cannot come to seek treatment here. I have to go to other facilities since I am worried about how I may be treated” Said one of the DHC members

“The support staff relates well with the nurse in charge. There were two support staff but we are surprised that he did not go while he was the one who was to be transferred” Said a monitor

“I wonder what times he sleeps. He is the watchman and during the day you will see him at the facility sometimes testing patients for malaria using the test kits. The community is not happy because they doubt his service since he did not go pas primary school.

Unity of purpose

Date(s): 19-12-2019

Region: Kwale County (Kinango village unit) Migundini ECDE.

Issue:

• Big cracks from the foundation to the lintel. The wall was almost collapsing.
• The foreman was always drunk and not able to supervise and guide the construction work.

What was the problem?

The walls.
It was observed that the laying of foundation was not well done. There is a type of rock that was not removed hence causing the wall to crack. The cracks started to develop when the building had reached the lintel stage. The crack became bigger with time making it impossible to continue with roofing.

The foreman.
The project committee and monitors complained about the foreman who was always drunk during the day. It was reported that sometimes he would disappear and not be seen at the site the whole day. He had identified a woman from the site who would update him on the number of people who have reported to work and also take stock of materials. The actual construction work was done without supervision by the foreman. The contractor was accused for being negligent by not supervising his own work.

Resolving the problem

The monitors held a meeting with the PMC and community to discuss how to fix the problem. They agreed to call the village admin to come and see the problems which they had identified earlier to see whether she will help them in solving the problem.

The village administrator visited the site together with the monitors. The village administrator took her time view on the construction to confirm whether the allegations were true, he too noticed the very same problems and contacted the contractor to confirm if she had noticed or had been told about the challenges. The contractor agreed to come on the site and ensure the problems are fixed.

What followed was a series of 3 meetings organised by the monitors. The first two meetings did not provide solutions to the problems. The last meeting brought together all stakeholders who include the monitors, community, the contractor, and various representatives from the County government including a representative from the CEC Education office.

75% of the problems were fixed and few months later the project was completed and handed over to the county government.

Results

The community is happy at least a number of problems have been fixed as per their expectations and the structure looks better. Some of their expectations were not met. For instance they expected the contractor to redo the foundation. This has given the community a reason to unite. Initially the community was divided and the contractor took this to his advantage. There were those siding with the contractor and did not mind about the problems while there were those who were against the contractor from the inception of the project. They just wanted to make things difficult for the contractor. They have come to understand that their actions will determine the quality of projects implemented in their area. They are now keen to follow up all projects in their area.
Monitors persistent follow up and use of evidence based approach contributed to fixing of problems. The village administrator and the sub county administrator were also supportive in giving directions and listening to the monitors and community. It showed the urgency and need to address the problems at hand. The workers shared the updates with the community members and some would as the monitors to confirm. In this way the community was updated on the progress. Some visited the project site to confirm. Initially the PMC were not willing to work with the monitors. They thought that there was an allocation for PMC and having monitors would mean that they also get a share. After being engaged by the monitors and seeing the role they played to identify and fix problems, a friendship was built and together they worked to ensure the project is completed.

Tsahuni ECDEC.
During ground breaking ceremony for Tsahuni ECDEC, the community received a hint from a government official that the contractor who built Migundini ECDE was awarded the tender to construct Tsahuni ECDEC. Having learnt about the experiences in Migundini, the community publicly refused to work with the contractor and a new contractor was identified to implement the project. Little did the community know that in the new company, the contractor at Migundini was a director and that it was a way of blackmailing the community to feel that they shall never suffer the same experiences realised at Migundini.
After the project implementation kick started, the community, PMCs’ and the monitors faced numerous challenges as far as materials were concerned but on raising their concerns to the village administrator he gave them no support and the same was replicated when they addressed the same to the contractor. For instance, with the poor quality of the type of sand and building blocks, there pleas fell on deaf ears but they never loosed hope that the contractor ought to do the right thing.
Following several meetings on ensuring that the problems were fixed, the monitors had to visit the office of the chief officer in charge of education who intervened on the matter and before making any decision he set a date of fact finding with the community which shall in one way inform his final decision. The community took advantage of him being a born and raised in the village to influence an outcome which really worked in their favour. On that particular day of the meeting, the chief officer after his numerous engagements with the community members, PMCs’ and the duty bearers, he come into a conclusion that something fishy was going on between the stakeholders and this was confirmed by the contractor who was trying to justify why the project had lots of problems that he was in agreement with the PMC chairman that he shall settle his two children school fees and in return support his shoddy work in implementation of the project.
After revealing of such a matter, the chief officer had to stop the chairman from his membership in the PMC and in an ultimatum of 21 days the contractor was ordered to fix the problems which after collapse of the said days the fixes were achieved. In one way it proved to us that the community through one of their own would achieve lots of fixes if only they collaborated for the common good of the society.