ReAct Africa  –  National Action Plans

NAP Implementation Support Kenya

ReAct Africa, among other partners, has supported and collaborated with the Kenyan Ministry of Health (MOH), right from the NAP development stage.

The Kenyan MOH developed and established its five-year National Action Plan (NAP) on Prevention and Containment of AMR in 2017, using the Global Action Plan on AMR as a blueprint, and guided by a preceding situational analysis. Since development, ReAct Africa  continues to support implementation of the Kenyan NAP.

Areas of Support

ReAct Africa aims to address 3 out of the 5 NAP objectives within the human health sector which are;

  • Objective 1

Improve awareness and understanding of antimicrobial resistance through effective communication, education and training.

  • Objective 3

Reduce the incidence of infection through effective sanitation, hygiene and IPC measures and

  • Objective 4

Optimize the use of antimicrobials in human health.

 

The results from the interventions under these three objectives also feed and inform objective 2: Strengthen the knowledge & evidence base through surveillance & research, by extension.

How we Support NAP Implementation in Kenya.

Over the years, support has taken various forms. For example;

  1. ReAct Africa has collaborated with the Kenyan MOH in the planning, launch and conducting of the World Antimicrobial Awareness Week (WAAW) activities every November since 2017. Other activities have ranged from engaging university students and HCWs in walk parades, from which members of the public and policy makers are made aware of AMR.
  2. Matters capacity building, ReAct Africa has trained health care workers (HCWs), primary school students, university students and civil society representatives on AMR and other associated fields such as Water sanitation and hygiene (WASH) and infection prevention and control (IPC).
  3. ReAct Africa has in collaboration with partners such as Africa CDC, engaged journalists to aid in simplifying the science around AMR and contextualizing the simplified information as communication pieces through different media platforms.
  4. To promote prudent use of antimicrobials in the healthcare sector, ReAct Africa engages counties through projects that aim to establish antimicrobial stewardship (AMS) programs through establishment of new or revival of dormant Medicines Therapeutic Committees (MTCs).

Promoting Optimal Antimicrobial Use & IPC in health care facilities.

Following the establishment of a formal agreement between with the Kenyan National Antimicrobial Steering Interagency Committee (NASIC) and ReAct Africa in late 2019, a Memorandum of Understanding (MOU) was established between ReAct Africa and the Makueni County Ministry of Health in March 2021, paving way for stewardship activities in the county. These activities were informed by a baseline study that was conducted by ReAct Africa, the Ecumenical Pharmaceutical Network (EPN) and the national AMR secretariat in March 2020, shortly before a nationwide lockdown was imposed in response to COVID-19.

General observations from the 7 assessed facilities showed that:

  • Antibiotic Stewardship was generally not in place. Antimicrobials were generally prescribed and diagnosed as per their availability.
  • All facilities had improvised hand washing points containing clean water and liquid soap, stationed in strategic areas within the compound. However, the wards were generally lacking this.
  • Injection techniques were commendable. However, aseptic procedures during injection practices were generally compromised by weak observation of the 5 moments of good hand hygiene.
  • Generally, the facilities did not have IPC and MTCs in place. The few existing ones were dormant.
  • Written IPC and Antibiotic Use policies and procedures lacked in general.
  • Waste management (especially segregation), good hand hygiene (especially before handling of patients) and equipment sterilization were areas that needed urgent attention in terms of capacity building. For example, Sodium Hypochlorite was still being used to sterilize equipment consequently leading to them developing rust.
MOU Signing
Dr. Andrew Mulwa (left) & Dr. Mirfin Mpundu (right) exhibiting the signed MOU; and the “gentleman’s elbow-shake”
The County Health Management Team and RAN team group photo, exhibiting the baseline study report

Owing to the COVID-19 national lockdown measures that were put in place shortly after conducting the baseline study, the planned project activities experienced unprecedented, extended delays. In fact, the baseline report manual was only presented to the then County Executive Committee (CEC) for Health, Makueni County – Dr. Andrew Mulwa during the signing of the MOU a year later, in March 2021. The 1st training-of-trainers (TOT) AMS workshop was only conducted 23rd-25th February 2021 and a 2nd one on 14th and 15th September 2021. The 1st training targeted HCWs from the 6 project facilities while the second one engaged HCWs from the remaining facilities. Both TOTs aimed to:

  1. Create awareness and understanding on AMR and factors that propagate development of AMR
  2. Build capacity on rational use of antimicrobials, principles of AMS, the importance of AMS committees and their association with MTC and IPC committees.
  3. Build capacity on how to conduct AMS audits.

Medical Superintendents for all facilities were sensitized on AMS on 28th May 2021 following a request from the CEC on the basis of them being in charge of the facilities’ operational budgets. Other than create awareness on AMR therefore, the sensitization meeting sought to get buy-in from the Med Sups for the AMS and IPC interventions that were proposed during the AMS TOT workshop in February 2021. It was also during this meeting that the Med Sups agreed that, HCWs from the remaining sub-county facilities benefit from a similar TOT. They also proposed that, through the project, an antibiogram for the county referral hospital be established and this would then act as a referral point for the entire county.

The first supervisory visit was conducted at the Kibwezi sub-county (SC) facility on 16th September 2021. The progress of the activities stated in the facility’s action plan during the February TOT were assessed using ReAct’s AMR supervisory visits tool and section 9 of the Ministry of Health’s IPC audit tool. The performance in the selected indicators were also compared to the observations made during the 2020 baseline study.

ReAct Africa is currently in the consultative phase with 2 other counties, in which similar interventions will be conducted.

Challenges of NAP implementation in Kenya

  • AMR Awareness.

AMR awareness activities do not have a lasting impact and as such need to be incorporated as part of other interventions rather than employ it solely.

  • Governance, leadership and commitment.

There is evident commitment at the national policy level. This has led to gradual albeit slow establishment of county antimicrobial resistance steering interagency committees (CASICs).  There is a general lack of prioritization to address AMR/AMS activities by the county health management teams (CHMTs) and facility administrations, perhaps owing to ignorance of AMR in general. Furthermore, there is duplication of interventions by different external partners. However, the national AMR secretariat recently established a national AMS Monitoring & Evaluation platform through which partner interventions are reported, to mitigate the situation.

  • Access to health commodities.

Fragile supply chain systems characterized by an over-reliance on an inefficient central medicines supplies agency and inaccessible roads in the remote rural areas among others, lead to chronic stock outs of both antimicrobials and reagents needed for laboratory tests.

  • Finances.

Scarcity in financial resources are a major barrier to optimal implementation of NAP activities. At the time that the NAP was developed and launched, no actual costs had been pegged to any implementation activity to guide partners and other concern stakeholders. Adequate funding is needed to invest in, and retain skilled human resource (and continued upskilling), current diagnostic equipment, integrated information and technology systems and to purchase adequate stocks of essential medicines and commodities, all of which generally lack in the health care facilities.

  • Paucity in submitting activity reports.

The implementing partners have their normal, demanding duties, in addition to the project activities. This compromises timely submission of reports. To date, only 4 out of the 6 AMS project facilities have submitted their reports.

Despite the challenges presented by the ongoing pandemic which has led to reallocation of funds and human resource, response interventions have resulted in boosting good hand washing practices at school, health facilities and community levels in general. Waste segregation has also improved at health care facility level.

Recommendations & Lessons learnt

Evidence-based behavior change interventions coupled with capacity building yield better impact compared to once-off or periodic awareness creation activities. The Alforja project, as well as COVID response-initiated activities for example, have led to an observed improvement in hand hygiene both at school and healthcare facilities. Such behavior change leads to reduced communicable infections which in turn lead to an overall reduction in use of antibiotics.

The need for multi-stakeholder collaborations and partner coordination, buoyed by political will and commitment cannot be over emphasized. Synergies derived from such collaborations result in effective achievement of desired outcomes and objectives. For example, a parallel intervention by an IPC stakeholder to conduct surgeries safely within Makueni County facilities, further strengthened IPC especially in performing caesarean sections and this in turn has led to reduced consumption of Ceftriaxone post-surgery. In addition, it strengthened the tracking of hospital acquired infections (HAIs) in the different wards.

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