Post Training Follow-up Assessment of Kenya Health Workforce Trainings 2012

Ministry of Health

March 2014

Post Training Follow-up Assessment of Kenya Health Workforce

Trainings 2012

March 2014

The views expressed in this document do not necessarily reflect the views of the United States Agency for International Development or the United States Government

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ACKNOWLEDGEMENTS

The Post Training Assessment (PTA) exercise was a collaborative effort of various stakeholders. The Ministry of Health wishes to acknowledge USAID and IntraHealth International lead FUNZOKenya project for funding and overall leadership specifically by; Peter Milo, Dr. Joyce Kinaro and Dr. Norbert Rakiro. We also recognize the regional hub managers; Isaac Munene, Benjamin Cheboi, Judith Karia, Rebecca Songoi, Mary Kamau, Mohammed Hussein, Ian Wanyoike and Allan Oginga for their input and coordinating role at the counties and Catherine Murphy from IntraHealth International Headquarters in Chapel Hill, USA for designing the draft assessment tool and reviewing the draft document and seeing it to its total completion.

We appreciate Moi University College of Health Sciences and the AMPATH Project for providing technical leadership and support. The secretariat from Moi University comprising Dr. Simiyu Tabu, Dr. Anne Mwangi, Edwin Sang, Joseph Koech, Andrew Busienei, Jepchirchir Kiplagat and Eunice Walumbe and all the research assistants.

The Ministry of Health looks forward to more collaborative research between the public and private sectors as best demonstrated in this assessment exercise.

Grace E. Odwako, Head-Human Resource Development Unit (HRD) Ministry of Health

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FOREWORD The government of Kenya’s (GOK) overall goal in health is to provide accessible, affordable and quality health care to all Kenyans. To achieve this target the ministry of health needs to have adequate human resources that are well trained to offer health services. According to the Constitution of Kenya (2010) training remains the mandate of the central government and in-service training for health workers need to be guided by clear training needs and above all should lead to improvement in service delivery at national and county levels as outlined in Vision 2030 and the Kenya Essential Package for Health (2005-2010).

According to the Report of the Training Needs Assessment of the Health Workforce in Kenya (MOH, 2012) it was observed that over 80% of in-service training is donor funded and each year the ministry of health spends colossal amounts of money on training. In addition, several days in a year are spent on training as health workers attended skill based trainings either at their facilities and or outside their duty stations.

With this background therefore this report has evaluated to what extend the trainings have contributed to improvements in service delivery in the country and identified barriers that hinder application of knowledge and skills post training. The evaluation result will be used to guide future trainings and advice donor support to the ministry. The report has made key recommendations on how in-service training is to be tailored to be more effective and explored opportunities for innovative learning methodologies that include e-learning among others that allow health workers to remain updated while offering critical health services. This document will go a long in improving training of health workforce and in turn improve service delivery in the health sector.

Prof. Fred H.K Segor, Principal Secretary, Ministry of Health

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TABLE OF CONTENTS ACKNOWLEDGEMENTS ..................................................................................................................... i TABLE OF CONTENTS ...................................................................................................................... iii LIST OF TABLES .................................................................................................................................. v LIST OF FIGURES ........................................................................................................................................ v LIST OF ABBREVIATIONS & ACRONYMS .................................................................................... vi FORWARD............................................................................................................................................ ii EXECUTIVE SUMMARY ................................................................................................................ viii CHAPTER ONE: INTRODUCTION ..................................................................................................... 1

Goal of the Post-Training Assessment ........................................................................................... 2 Objectives .......................................................................................................................................... 2

CHAPTER TWO: DESIGNS AND METHODS ................................................................................... 4 Population ......................................................................................................................................... 4 Sample ............................................................................................................................................... 4 Sampling Technique ......................................................................................................................... 4 Data Collection .................................................................................................................................. 4 Pilot Testing ....................................................................................................................................... 5 Mapping of the Region .................................................................................................................... 5 Data Quality and Confidentiality .................................................................................................... 5 Data Entry .......................................................................................................................................... 5 Data Analysis ..................................................................................................................................... 6 Focus Group Discussion ................................................................................................................... 6 Limitations of the Study ................................................................................................................... 6

CHAPTER THREE: FINDINGS ............................................................................................................ 7 Response Rate ................................................................................................................................... 7 Quantitative Results ......................................................................................................................... 8

Service Delivery ........................................................................................................................... 10 Enabling Factors and Barriers to Service Delivery .................................................................. 12 Challenges ................................................................................................................................... 13 Professional development ......................................................................................................... 13 Proposed Improvements in the Trainings ............................................................................... 13 Recommendation for Other Trainings ..................................................................................... 14

Findings from the Focus Group Discussions (FGDs) .................................................................. 14 Infrastructure ............................................................................................................................... 14 Consumable resources ............................................................................................................... 14 Skills inventory/ human resource ............................................................................................. 15 Selection criteria ......................................................................................................................... 15 Mentorship/Follow up ................................................................................................................ 16 Mentorship guidelines ............................................................................................................... 17 Communication and coordination ........................................................................................... 17 Interagency collaboration .......................................................................................................... 17 Training curriculum..................................................................................................................... 18 Coordination of training ............................................................................................................ 18

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Training logistics ......................................................................................................................... 18 Trainers ......................................................................................................................................... 18 Focal person/ coordination ....................................................................................................... 18 Certification and accreditation to offer service ...................................................................... 19 Placement and posting .............................................................................................................. 19 On-the-job training .................................................................................................................... 19

Benefits of trainings support ........................................................................................................ 19 Areas of Improvement ................................................................................................................... 19 Barriers & Challenges to Service Provision by the Trainees ..................................................... 20 Summary Findings from Supervisor Interviews .......................................................................... 21

Duties and Services offered by the supervisor ....................................................................... 21 Reason for change in provision of services by trainee .......................................................... 21 Changes in quality of service delivery ...................................................................................... 21 Changes in quantity of service delivery ................................................................................... 21 Forms of supportive supervision .............................................................................................. 21 Available opportunities for continuing professional development ..................................... 21 Comments on training that would improve service delivery in your facility ...................... 22 Recommendations for improvement of the trainings ........................................................... 22

CHAPTER FOUR: DISCUSSION ....................................................................................................... 23 CHAPTER FIVE: CONCLUSIONS AND RECOMMENDATIONS ................................................. 27 RECOMMENDATIONS ...................................................................................................................... 28 REFERENCES ..................................................................................................................................... 29 APPENDICES ...................................................................................................................................... 31 APPENDIX 1- CONSENT FORM RA Code: ___________ .................................................. 31 APPENDIX 2- TRAINING FOLLOW-UP PARTICIPANT’S QUESTIONNAIRE ........................... 33 APPENDIX 3- POST TRAINING FOLLOW-UP SUPERVISOR’S QUESTIONNAIRE ................. 41 APPENDIX 4: POST TRAINING FOLLOW-UP CHECKLIST ......................................................... 46 APPENDIX 5- POST TRAINING FOLLOW-UP GUIDE FOR FOCUSED GROUP DISCUSSION (FGD) .................................................................................................................................................... 47 APPENDIX 6: RESEARCH ASSISTANTS ........................................................................................ 50 APPENDIX 7: ADVISORY GROUP................................................................................................... 50 APPENDIX 8: SECRETARIAT ........................................................................................................... 50 APPENDIX 9: Transfer Matrix and Trainee Support Framework ....................................................... 51 Modified from Broad (2005)................................................................................................................. 51 APPENDIX 10: Muchs-FUNZOKenya Post-training Assessment Schedule ....................................... 52 APPENDIX 11: Letter from the Human Resources Department, MOH .............................................. 53

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LIST OF TABLES Table 1: Socio-demographic characteristics of trainees ............................................................................ 8 Table 2: Training assessed and facility type ................................................................................................... 9 Table 3: Change in Service offered before and after training .............................................................. 10 Table 4: Enabling factors and barriers to training ................................................................................... 12 Table 5: Challenges to service delivery ......................................................................................................... 13 LIST OF FIGURES Figure 1: Communication Channel during the Assessment Exercise ............................................. 3

Figure 2: Distribution of Respondents by region ............................................................................. 7

Figure 3: Type of in-service training (n=282) .................................................................................... 9

Figure 4: Services Offered Daily ........................................................................................................ 11

Figure 5: Supporting and Inhibiting Factors for Intention to Transfer, adapted from Foxon, 2002 ...................................................................................................................................................... 25

Figure 6: Three-factor model of transfer ......................................................................................... 25

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LIST OF ABBREVIATIONS & ACRONYMS AMSTL - Active Management of Third Stage of Labor APHIA - Aids Population Health Integrated Assistance ART - Anti-Retroviral Therapy CHS - College of Health Sciences CHS - College of Health Sciences CO - Clinical Officer DASCO - District AIDS and STI Control Officer DCAH - Division of Child and Adolescent Health DFH - Department of Family Health DHMT - District Health Management Team DMOH - District Medical Officer of Health DPHN - District Public Health Nurse DRH - Division of Reproductive Health EMNC - Essential Maternal Newborn Care EMOC - Emergency Obstetric Care), ENC - New Born Care EOC - Essential Obstetric Care FANC - Focused Antenatal Care FBOs - Faith-Based Organizations FGD - Focus Group Discussion GBV - Gender Based Violence GOK - Government of Kenya HIV - Human Immunodeficiency Virus HMIS - Health Management Information System HRD - Human Resource Development HRH - Human Resource for Health HRM - Human Resources Management IMAI - Integrated Management of Adulthood Illnesses IMCI - Integrated Management of Childhood illness LAPM - Long Acting and Permanent Methods LAPM-FP - Long Acting and Permanent Methods of Family Planning LIMS - Laboratory Information Management Systems M&E - Monitoring and Evaluation MCH - Maternal and Child Health MCM - Malaria Case Management MDR-TB - Multi-Drug Resistant Tuberculosis MO - Medical Officer MOH - Ministry of Health MOMS - Ministry of Medical Services MUCHS - Moi University College of Health Sciences NACC - National AIDS Control Council NASCOP - Kenya National AIDS and STI Control Programme NEP - North Eastern Province PHO - Public Health Officer

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PMO - Provincial Medical Officer PMTCT - Prevention of Mother-to-Child Transmission TB - Tuberculosis TNA - Training Needs Assessment USG - United States Government VCT - Voluntary Counseling and Testing

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EXECUTIVE SUMMARY Background and Objectives The post-training follow-up assessment conducted between October and November, 2013, was commissioned by the Ministry of Health (MOH) through the Human Resource Development (HRD) department to establish the extent to which health workers in Government of Kenya (GOK), faith-based organizations (FBO) and private health facilities integrated training knowledge and skills into their job performance, analyze whether application of learning resulted in a change in the quality or quantity of services offered, and identify barriers if any, towards performance of their work. Methodology The study was a cross-sectional survey, with respondents proportionately selected across the country utilizing both qualitative and quantitative methods. The survey targeted 300 respondents out of the 1662 health workers that underwent in-service training from August through December 2012. Interviews were conducted from September 30 to October 11, 2013. Trainee, supervisor and focus group discussion (FGD) tools were developed and 21 research assistants recruited, trained, and distributed across the country to administer the tools. Prior to the data collection, a pilot study was conducted on 23rd September 2013, and minor revisions made on the tools. The draft report was shared with the stakeholders in a meeting held on January 22nd, 2014 in Nairobi. Stakeholders in the meeting comprised of MOH- HRD, MOH technical departments and divisions, regulatory authorities, training institutions and partners that included representatives from the USAID APHIAPlus projects and their feedback used to improve the final report. Summary Findings Out of the initial target of 300 respondents, 282 were interviewed. The female to male ratio was 71:19 with a median age of 36 years (IQR: 30, 44). Of the total interviewees, 232 (82%) were nurses, with 201 (71%) having been in service for more than 5 years. 25% of the trainees reported to have been transferred from their duty stations after training. More health workers from the public facilities had received training compared to those from FBOs and private. Of the 282 health workers interviewed 256 (92%) worked in public facilities. Most of the respondents had previously attended other trainings besides those supported by FUNZOKenya. Of all the trainings assessed, prevention of mother-to-child transmission (PMTCT), 86 (31%) and cervical cancer screening, 61(22%) had the highest number of trainees. Amongst regions, the Rift Valley province had the highest number of trainees at 65 (23%), while Nyanza had the least at 9 (3%). One hundred and seventy eight (63%) respondents reported to have provided the services prior to the training; after the training, the number increased to 247 (88%). Also, the number of patients seen at the facility 6 months pre/post-training was found to have significantly increased (p-value=0.0332). The supervisors confirmed there had been a change in service provision with over 60% reporting positive change. The proportion of participants who offered the service on a daily basis drastically increased post-training for all the services

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except for Essential Maternal and New born Care (EMNC). The change in quality cited was due to increased accuracy in diagnosis, increased client satisfaction, reduced waiting time, improved record keeping, positive change of attitude among health workers, increased uptake of services, improved treatment outcomes, improved procurement of equipment and supplies, fewer referrals and increased patient confidentiality. Acquisition of knowledge and skills (85%) and increase in level of confidence (65%) were reported through increased services provided post-training. The trainees however reported factors that hindered service delivery, including stock out of supplies/equipment/instruments (37%), inadequate physical environment (31%), staff rotation (27%), and lack of motivation and culture/religion (23%). The trained health workers who reported not offering the service explained that their current positions was not relevant to the training received (46%) or staff movement/posted to another location in the facility (26%) were their limitations. After the training, 149 (53%) of the participants reported having received mentorship, while 239 (85%) reported to have offered mentorship to colleagues within the facilities. The 47% who did not receive mentorship attributed it to lack of financial incentives to motivate mentors, unavailability of mentors and understaffing, poor accessibility to facility and high staff turn-over. Supportive supervision was reported available by 225 (85%) of the participants interviewed. Conclusions The report concluded that there was an improvement in quality and quantity of services provided in the 12 training areas after the trainings. There was significant knowledge transfer demonstrated through improved level of confidence during service delivery. Key Recommendations The majority of trainees had more than five years’ experience. This group could be utilized in the development and delivery of on-the-job trainings, mentorship and supervision and responsive, innovative teaching methodologies. There is need to appoint focal persons on the ground to participate in trainee selection. Efforts should be made to increase commodity supplies at facilities, provide performance-based rewards for trainees that implement training at their posting. Recommendations were made to conduct trainings in additional specialties, such as non-communicable disease (NCDs), malaria, monitoring and evaluation (M&E) among others.

CHAPTER ONE: INTRODUCTION The Government of Kenya (GOK) is committed to improving access to and quality of essential health services in the country. In order to reach the goals outlined in the Kenya Health Sector Strategic and Investment Plan 2013-2017, provision of a well-managed, equitably distributed, and appropriately skilled health workforce is critical. Chen L, et al. (2004) identified challenges to building an effective health workforce, such as low absolute numbers of trained workforce, difficulties in recruiting and managing health workers, impact of HIV on the health workforce, and poor performance. According to the World Health Organization (WHO), Kenya is one of the 57 countries with acute manpower shortages in the health sector (2006). Workforce shortage is a relative term, influenced by other variables such as imbalances, misdistribution, and worker performance (Joint Learning Initiative, 2004). The Kenya National HRH Strategic Plan 2009-2012, identified the following HRH challenges: inadequate distribution of health workers, high attrition, outmigration, weak human resource management systems, weak leadership and management capacity, weaknesses in in-service and pre-service training, poor sectoral coordination of the HRH agenda. The Ministry of Health (MOH) Human Resource Development (HRD) is receiving support from FUNZOKenya, a USAID-funded, IntraHealth International-led project, whose goal is to transform health training throughout the country by improving training delivery, increasing the admissions’ capacity of pre-service training institutions, link training to health worker re-licensure, and increase the capacity of regulatory bodies to accredit and monitor training. FUNZOKenya provides technical support to the GOK, national, county and district stakeholders, private providers, FBOs and United States Government (USG) implementing partners and other stakeholders working in Kenya to transform health workforce training. In order to understand the context of in-service health workers training, the MOH-HRD conducted a Training Needs Assessment (TNA) and a Baseline Survey between June and August 2012. The TNA established the following as key priority areas of service delivery that required attention:

• Cervical cancer screening, prevention of mother to child transmission of HIV (PMTCT), pediatric HIV,

• Focused antenatal care (FANC), • Integrated management of childhood illness (IMCI), • New born care (ENC), • Active management of third stage of labor (AMSTL)/essential obstetric care (EOC)

and • Commodity management.

The FUNZOKenya supported MOH to train 1,662 heath workers between August and December 2012, on cervical cancer screening, PMTCT, pediatric HIV, long acting and permanent methods (LAPM) of family planning, IMCI, essential maternal newborn care (EMNC), commodity management, FANC, multi-drug resistant TB (MDR-TB) and clinical management of sexual violence/gender based violence (GBV).

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The training curricula was developed and prescribed by MOH technical departments and divisions such as the National AIDS and STDs Control Programme (NASCOP), Division of Reproductive Health (DRH) and Division of Child and Adolescent Health (DCAH) among others. The course trainers were MOH staff certified by the relevant technical departments and divisions as mentioned above. The course trainees where identified by MOH, in consultation with the APHIAPlus partners, for relevant regions and MOH technical focal persons at the provincial levels. The trainees were notified of their attendance to the training one week prior to the start date. Each class had a maximum of 30 trainees, with the exception of IMCI, which had a class of 24 participants. The participants represented many cadres and facilities, comprised of GOK, FBOs and private sectors. The training targeted those who had not attended previous in-service trainings for the same skills and served relevant department of the health facility/hospital. The training venues were hotels and training institutions in respective counties. Against this background, the post-training follow-up was to evaluate service providers at least six months post-training with an adequate sample size drawn from those trained in 2012. This aspect addresses one of FUNZOKenya’s overarching goals: Intermediate Result 2—to address existing health workforce gaps in skills and knowledge for professional development by supporting current health workers training needs. Moi University College of Health Sciences (MUCHS) was identified by FUNZOKenya, in consultation with the MOH- HRD to lead the Post Training Assessment (PTA). The assessment targeted a representative sample of 300 of the 1662 health workers who were trained during the period August-December 2012, from across 47 counties with corresponding number of immediate (line) supervisors.

Goal of the Post-Training Assessment

The goal of this training follow-up activity was to evaluate how the knowledge and skills acquired by health workers (trainees) supported for training were integrated into their job performance.

Objectives

1. Determine extent to which trainees were able to apply the acquired skills 2. Analyze whether application of learning in the context of work resulted in a change

in the quality or quantity of services offered 3. Describe barriers if any, experienced by the trainees towards performance of their

work.

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The exercise would not have been conducted successfully without the communication channel shown below (Fig. 1):

Figure 1: Communication Channel during the Assessment Exercise

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CHAPTER TWO: DESIGNS AND METHODS A trainee-based cross-sectional survey, employing quantitative and qualitative research methods, was used to collect data for the PTA. The quantitative data was collected between 30 September and 11 October 2013, using researcher-administered semi-structured questionnaires. The qualitative data was collected on the 3rd, 7th and 11th October 2013, at Nakuru, Mombasa, and Garissa targeting South Rift, Coast, and North Eastern regions respectively. The three FGDs had 6-8 members each based on predetermined criteria.

Population

The participants involved in the study were healthworkers trained with support from FUNZOKenya between August and December 2012. A total of 1,662 service providers from the 8 regions (former administrative provinces in Kenya) of mixed cadre and from different types of facilities were trained during that period.

Sample

A subset was selected from the population, representing the former eight provinces and the different trainings.

Sampling Technique

The sampling frame for the exercise, 1,662 health workers recently-trained, was provided by FUNZOKenya. Stratified random sampling was used to select the 300 participants from the population; the variables were region (province) and type of training. The sampling was conducted using STATA version 10, proportionate to the size of the trained personnel per region. The immediate/line supervisors for the sampled trainees were eligible for the supervisors’ interview. For the FGDs, three regions were selected based on the geographical distribution, culture and beliefs, healthcare capacities, and distance to health facilities. The members of the FGD comprised of District Public Health Nurse (DPHN), Medical Officer (MO), Public Health Officer (PHO), representative of the women support group, HIV support group, head of health facilities, APHIAPlus representative and other interested parties. The membership represented leadership within the Health sector and level of activity in terms of morbid conditions. The FGDs were carried out using a standard guide and proceedings were recorded using digital voice recorders.

Data Collection

Two semi-structured interview questionnaires were used to collect data: the participants and the supervisor’s questionnaires. The contents of the questionnaires were based on model questionnaires provided by FUNZOKenya that underwent revision. The revisions were done through a consultative process between relevant stakeholders including MOH-HRD, technical

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departments and divisions, regulatory authorities, APHIAPlus, MUCHS, and other key partners.

Pilot Testing

Research assistants (RAs) were recruited by MUCHS in mid-September based on a set of qualifications, which included a minimum of bachelor’s degree in a health related field, previous research experience, and availability. A total of 21 RAs were recruited and trained on the data collection tools prior to the pilot study. The pilot carried out on 23rd September 2013, included: testing the procedures, questionnaires, and data capture systems in a limited subset of the facilities near MUCHS. The participants included in the pilot were not part of those recruited for the assessment. Authority to visit the various health facilities was obtained from the MOH-HRD office (see Appendix 11) and respective county and facility heads. Thereafter, data entry, analysis, and cleaning took another ten days (see annex of work plan). The results of the pilot were used to modify the evaluation implementation tools. Through the pilot testing, the team assessed comprehension, acceptance, feasibility, and other factors that influence how the processes would fit into the schedules of the health care provider. Further refinement was completed following the pilot.

Mapping of the Region

The study mapped the sampled trainees in the eight ‘former’ provinces in order to ensure seamless implementation of the main exercise in terms of time and cost. The mapping was based on the training facilities with the assistance of FUNZOKenya regional hub managers. The trained RAs were divided into 11 teams of 2. The teams were then distributed according to their knowledge of the eight regions with some regions having more than one team due to high number of participants.

Data Quality and Confidentiality

To ensure confidentiality of the trainees and supervisors, each participant was assigned a unique identification number instead of using their names. The questionnaires were reviewed every day by the team leaders to check for inconsistencies and missing data.

Data Entry

Microsoft Access database was developed for the management of the data. RAs were trained on how to enter data using user friendly interface forms. As a result of the "noise" in the unstructured questions (e.g. illegible writing) and the lack of precision in natural language, the data extracted by different RAs from the same documents may differ. These are potential sources of error. To reduce the potential for these sources of error, RAs entered the data that they collected.

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The data was then analyzed through a series of data checking operations to verify that data values were correct.

Data Analysis

Quantitative data were exported into SAS version 9.3 for analysis. Descriptive statistics, such as frequency listings and percentages, were used for categorical variables. Significance tests were carried out using Kruskal Wallis and chi-square tests where appropriate. Cross tabulation of responses by type of training were conducted to illustrate comparisons.

Focus Group Discussion

The FGD interview guide was developed alongside the other quantitative tools. It went through a review process similar to the other tools. The identified participants were invited for discussion on the 3rd, 7th and 11th of October, 2013, to South Rift, Coast and North-Eastern FGDs respectively. Each group had six to eight participants in attendance. For the actual FGD, a moderator, an observer and a recorder were identified. After introduction of those in attendance, verbal consent was received from attendees and roles explained to participants before beginning the interview. Each interview was recorded using two digital audio recorders. The observer and recorder took detailed notes during the interview. After the interview, the data from the FGD was transcribed and subsequently coded. Analysis was achieved through use of scissor–and-sort technique and themes were developed. Some of the themes were merged with the interview guide and the quantitative tool.

Limitations of the Study

Some factors were beyond the study’s control and may have biased the findings. These include: inaccuracies of participants’ data (e.g. incorrect phone numbers or names of participants), hard to reach facilities which limited contact time and access, 54 replacements of respondents for various reasons, a high staff turnover that involved both trainees and their supervisors and change of workstation by health workers within a short time, and poor recall as that the survey was conducted one year after the training. Some aspects of quality of service were difficult to objectively measure in the absence of the user of services (the client).

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CHAPTER THREE: FINDINGS This chapter summarizes the socio-demographic summary, the extent by which knowledge and skill was applied, the outcome of the trainings and obstacles for successful transfer of the knowledge and skill, and some of the findings which may be classified as Aberrant.

Response Rate

A total of 300 participants were sampled, of which 228 were successfully interviewed. The distribution of participants was as per the figure 2 below;

Figure 2: Distribution of Respondents by region

The remaining participants in the original sample were not available for the interview, because they were on leave, attending training, were trainers themselves, or could not be reached via phone. These participants were replaced by 54 other matched trainees (same region, similar training, same training period) bringing the total interviewed to 282. The response rate was thus 94% (282/300). We interviewed 245 supervisors out of the target 236. The interesting finding was that in Western Kenya, each trainee had a supervisor.

24 (9%)

65 (23%)

17 (6%)

38 (13%)

54 (19%)

50 (18%)

9 (3%)

25 (9%)

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Quantitative Results

Table 1 below shows the socio-demographic characteristics of the participants. The median age in years was 36 (IQR: 30, 44). Out of the 282 participants, 199 (71%) were females, 232 (82%) were nurses, and 201 (71%) had been in service for more than 5 years. Table 1: Socio-demographic Characteristics of Trainees

Age in years Mean (std) Median (IQR)

n=189 37.64 (9.48) 36 (30,44)

Age in years Mean (std) Median (IQR)Gender Female Male

n=189∗ 37.64 (9.48) 36 (30,44)n=282 199 83

70.6 29.4

Cadre CO HR Lab Tech MO Nurse PHO

n=282 199 38 1 5 2 232 4

70.6 29.413.48 0.35 1.77 0.71 82.27 1.42

Cadre CO HR Lab Tech MO Nurse PHO

n=282 38 1 5 2 232 4

13.48 0.35 1.77 0.71 82.27 1.42

Highest Education Basic Degree Certificate Diploma Higher Diploma Other Post Graduate

n=282 12 54 202 5 4 5

4.26 19.15 71.63 1.77 1.42 1.77

Years of Service < 1 1 - 3 > 3 - 5 > 5

n=282 1 40 40 201

0.35 14.18 14.18 71.28

∗ 93 respondents declined to give their age

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A total of 282 trainees participated in the exercise, with a majority of 256 (92%) working in public facilities. Of the trainings assessed, PMTCT had the highest number of participants at 86 (31%), followed closely by cervical cancer screening at 61 (22%), adult ART 15.3%, and MDR-TB 10%. Two hundred and forty five supervisors were interviewed. In some cases, more than one trainee reported to one supervisor. Rift Valley province had the highest number of trainees at 65 (23%), while Nyanza had the least at 9 (3%). Most of the respondents had previously attended other trainings apart from the one supported by FUNZOKenya, some trainings were similar but others were different, such as basic life support, management of malaria, M&E, diabetes, and health management information.

Figure 3: Type of in-service training (n=282)

From the bar chart above, PMTCT and cervical cancer screening formed the majority of trainings supported country-wide (Fig. 3). Nine out of every ten facilities were public as per the Table 2 below.

Table 2: Training Assessed and Facility Type Variable Freq %(100)

Type of Facility FBO NGO Private Public

n=282 15 2 9 256

5.32 0.71 3.19 90.78

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Service Delivery All the participants had more than one responsibility at their station, multitasking between clinical clerkships, administering drugs and/or general administrative duties. 68 (24%) of the trainees reported changing their duty station after training. To assess the impact of the training on service delivery, the participants were asked whether they were offering service related to the training both pre- and post- training. Prior to the training, 178 (63%) of the respondents reported to have offered the respective services they were trained in. After the training, the number increased to 247 (88%). This increase was found to be statistically significant (χ2 p-value < 0.0001). The number of patients seen at the facility six months pre and post training was also found to have increased significantly (Kruskal Wallis p-value=0.0332). The participants cited lack of knowledge and skills, job placement, lack of equipment, supplies, and a lack of accreditation as main reasons for not offering the services prior to the training. Most of the services recorded an improvement in type of training and frequency of services provided as per the Table 3 below.

Table 3: Change in Service Offered Before and After Training Variable Freq % Change in section/ service area/department before and after training C=Change NC=No Change

n=281* 68 213

24.20 75.80

Service offered before Training No Yes

n=282 104 178

36.88 63.12

Service offered after Training No Yes

n=282 35 247

12.41 87.59

Patients seen per month before training (Jan- June 2012) Mean (std) Median (IQR)

n=173 128.05 (224.29) 40 (10,156)

Patients seen per month after training Mean (std) Median (IQR)

n=224 165.46 (446.16) 43 (14,200)

Services offered after training Adult ART Management Cervical Cancer Screening Commodity Management EMNC EMOC FANC GBV IMCI LAPM_FP

n=245 71 74 28 28 14 41 22 48 38

28.98 30.20 11.43 11.43 5.71 16.73 8.98 19.59 15.51

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Multidrug Resistant TB Others(specify) PMTCT Pediatric ART Management

37 15 111 35

15.10 6.12 45.31 14.29

* One was non-respondent There was a drastic increase in the proportion of participants offering service on a daily basis except for EMNC as shown in the figure below (Fig. 4).

Figure 4: Services Offered Daily

The main reasons for low frequency of the service prior to training were: low demand for the service, shortage of staff, lack of adequate knowledge and skills, lack of resources and space - hence most of the patients were referred to other facilities. On the other hand, the main reasons for the increased frequency of the service after the training were: increased uptake of the service, availability of drugs and supplies, acquisition of skills and having more staff trained in the facility, mentorship and support from higher authority, and sensitization of patients on the availability of the service hence increasing the demand. The same reasons were reported by the supervisors for the increased frequency in the provision of service delivery by the training participants.

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Supervisors reported improved quality of services, including: improved patient safety, accuracy of diagnosis, client satisfaction, better record keeping, faster decision making, better treatment outcomes, procurement of equipment and supplies, reduction in waiting time, fewer referrals, and change of attitude amongst health providers. The supervisors also reported a positive change in numbers of health workers trained, which included: ability to attend to more patients in a short time, availability of commodities, increase service uptake, and increased frequency in service delivery.

Enabling Factors and Barriers to Service Delivery

Improvements in service delivery as reported by the participants who were offering the services was due to acquisition of knowledge and skills (85%), and increase in level of confidence (65%). Very few reported appraisal and incentives to perform as expected (4%) as the enabling factor for improved service delivery after the training. For those who reported not offering the service despite receiving training, they cited current position not being relevant to the training they received (46%), followed by staff movement/posted to another location in the facility (26%). Other findings point to participant selection for the course and need for policy direction at facility and HRD level on training and its application at the workplace. Lack of resources, such as fuel and allowances for staff conducting follow-up, was cited as a hindrance to implementation of mentorship programs. It was also noted that in some instances, training needs assessment (TNA) was conducted with little support from partners.

Table 4: Enabling Factors and Barriers to Training Variable Freq % Factors enabling improved service provision post training Acquisition of skills and knowledge required to do the job Appraisal and incentives to perform as expected Availability of supplies equipment instruments Current position relevant to the service procedure Feedback from supervisors High demand for the services Increase in the level of confidence in skills Others(Please specify) Service procedure trained in now provided in the facility

n=247 211 11 60 65 43 72 160 59 35

85.43 4.45 24.29 26.32 17.41 29.15 64.78 23.89 14.17

Barriers to service provision post training Current position not relevant to the service procedure Inadequate physical environment including proper tools supplies Lack of clear and immediate feedback from supervisors Lack of clear job description Lack of motivation Low demand low client caseload Others(Please specify) Service procedure trained in is not provided in the facility

n=35 16 7 1 1 4 14 2 9

45.71 20.00 2.86 2.86 11.43 40.00 5.71 25.71

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Variable Freq % Staff rotation movement to different section facility 3 8.57

Challenges The participants reported the following challenges in service delivery, including: stock out of supplies/equipment/instruments (37%), inadequate physical environment (31%), staff rotation (27%), lack of motivation and incentives (23%), and religion (23%). Other factors mentioned as hindrances, included: shortage of staff, limited finances, lack of regular updates/CME/handouts, and loss to follow-up of clients (Table 5 below). Table 5: Challenges to Service Delivery

Challenges in service delivery Culture religion Current position not relevant to the service procedure Inadequate physical environment including proper tools supplies Lack of clear and immediate feedback from supervisors Lack of clear job description Lack of confidence in skills Lack of motivation and incentives to perform as expected Lack of skills and knowledge required to do the job Low demand low client caseload Others (Please specify) Service procedure trained in is not provided in the facility Staff rotation movement to different section facility Stock out of supplies equipment instruments

n=248 57 13 78 20 15 3 58 14 30 153 1 67 91

22.98 5.24 31.45 8.06 6.05 1.21 23.39 5.65 12.10 61.69 0.40 27.02 36.69

Professional development One hundred and forty nine (53%) of the participants reported receiving mentorship post-training, while 239 (85%) reported to have offered mentorship to other service providers in their facilities. For the 47% who did not receive mentorship, the reasons provided were lack of financial support to mentors, lack of mentors, understaffing, poor accessibility to facility, and high staff turn-over. Two hundred and twenty five (80%) of the participants interviewed reported that supportive supervision was available post-training. The type of supportive supervision included: updates from APHIAPlus, quarterly reports, CMEs and seminars, support from DASCO/DCO/DPHN/DHMT/DMOH/DPHN and MOH, on the job training, refresher courses, appraisals and regular meetings with supervisor.

Proposed Improvements in the Trainings The main areas that require improvement are:

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• The need for flexibility of paying allowances • Need for Frequent updates on trainings • Provision of refresher courses • Certificates provided on time • Training period should be increased • Elimination of bias in selection of trainees • Mentorship • Provision of supplies and equipment • Follow-up after training • Provision of handouts • More time should be spent on practical and demonstrations • More staff should be trained in one facility to ensure that facility coverage

Recommendation for Other Trainings Apart from trainings already currently supported by FUNZOKenya, the following trainings were recommended by participants: IMAI, LIMS, M&E, EMOC, malaria case management (MCM), psychology and counseling, attitude and work ethics, and laboratory courses. The supervisors generally acknowledged the quality work performed by the trainees following the training. They endorsed similar trainings as the participants, in addition to malaria management and comprehensive care center. They also recommended increased training of in the facilities due to staff rotation, in addition to provision of supplies and equipment to the trainees.

Findings from the Focus Group Discussions (FGDs)

Infrastructure Lack of adequate infrastructure and upgrading of the different areas came out clearly during discussion. In North Eastern Province (NEP), resource challenges are experienced during services, such as cervical cancer screening. The case was similar for essential maternal and newborn care. Further, the participants indicated that the Provincial General Hospital (PGH) had no functional laboratory to comprehensively deal with cancer cases. “PGH Garissa has no cytology laboratory despite having trained staffs including consultant pathologist. The good news is that one NGO called SIMAHO has a chemotherapy machine sponsored by a partner.” (FGD Participant, NEP). South Rift too had a similar problem of lack of adequate infrastructure especially in the rural and far to reach facilities. Consumable resources The supply of materials was not adequate. It was reported that. ‘’there are stock-outs because fewer materials are supplied or they are supplied late and there is delay in communication for stock outs in the facility’’, (FGD participants said). They also stated that there is discrepancy between what is ordered and what is supplied. The reagents are not supplied centrally and it depends on the type of the facility and some facilities are not in a position to order for themselves. The South Rift group further noted that the PUSH system of drugs in the past led to most drugs expiring, and the PULL system had reduced the problem. ART coordinator (MOH employees) and pharmacists consulted with neighboring districts to make sure they do not

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misuse drugs. They also suggested that there should be mentorship for accounting for commodities; for consumables, partners should work to supply reagents. Skills inventory/ human resource From the discussions, it emerged that there is no skill inventory for any cadre of staff whom have been trained in various fields. If only a few officers are trained from each facility and then transferred or leave, the health service capacity of the facility will decrease. More officers should be trained to fill this gap and reduce the stress associated with movements and rotations of staff. “The maintenance of skill inventory is also important to in-charges and county directors in selecting participants for training. Poor skills inventory on the health facilities meant that the use of data was minimal in determining participants for training and that some participants would undergo training on ten different courses while others are left out” (FGD participant). The feeling was that the facility managers need to maintain quality data on the staff members and in future, it is necessary to train facility managers on data management. MOH Human resources could be linked with data from the institution or health facility to ensure that they are aware of who has attended which training and who needs a specific training. This will help avoid one person being trained in many courses and service delivery areas. Most staffs are employed on contract basis and are temporary status, especially those employed by partners. Furthermore, staff that is poorly remunerated can result in turnover and gaps in health service delivery. This is common in North Eastern Region, where staff tend to seek transfers to places near their homes due to hardships in the region while others are advancing their studies in universities and colleges in Nairobi, limiting their availability to offer services trained. Due to staff rotation, the trainee might not be able to apply the skills acquired from the training adequately, “a vicious cycle of re-training because of staff transfers” (FGD participant). Selection criteria There is need for clear criteria for selecting training participants. There is also need for proper skills inventory to ensure that participants are considered before the training is offered. This was reported clearly from the discussions. It was reported that some staff attend duplicative trainings, further supporting the need to streamline the selection criteria. It came out clearly that some staffs were continually attending trainings at the expense of their duties, resulting in limited time available to apply knowledge and skills gained from the training.

“I can say without fear that there are officers who are in perpetual trainings and I do not want that. I don’t want to hear county public officer, county nutritionist and CASCO. I don’t want this...” (FGD Participant).

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Another issue raised was the shortage of staff, which has resulted in challenges during trainee selection since some facilities have only one health worker who is the only option to be trained. As a result, the same staff may be trained over and over again, but in the event that he or she is transferred, he moves on with the skills acquired, leaving a gap in services provided in the facilities. During the NEP region discussion, medical officers were not sponsored for training, but nurses and clinical officers were. This was also reported as a setback to the success of the health service delivery trainings offered since it is doctors who do ward rounds and interact with patients more in higher level facilities (e.g. district hospitals and the PGH Garissa). However, it was also noted that the doctors had no time to be trained for as long as a whole week due to the large volumes of work they have. Further, doctors did not find the trainings supported particularly useful as they were not conducted by senior doctors or professors, The participants suggested that the selection criteria used by MOH to choose trainees needs to capture doctors as well and that trainers should be doctors for the clinical trainings. Further issues raised reported that training health workers who were in a different department restricts the trainee from applying knowledge gained. It was also noted that the trainees did not inform the facility in-charges on the training that they received. ‘The Facility does not have information on who has been trained and on what.’’ Mentorship/Follow up There is a high need for follow up after the trainings. Currently, there are no follow up mechanisms on the trainings sponsored by FUNZOKenya. A suggestion was made on the need to develop clear guidelines that indicate how a participant can apply the training skills acquired at the workplace. An action plan and team should be set up to guide the follow up process. In the NEP region, there was no mentorship programs due to limited resources, such as fuel and per diem for staff conducting follow up. However, they stated that a baseline survey for TNA was conducted with support from partners. Lack of mentorship program was mainly due to absence of clear guidelines; this negatively affected the ability to provide effective health care services. In addition, there was need for further placements and supervision. One of the participants stressed, “It is impossible to be an expert in a certain health field after the short course training. You cannot claim that one who has been trained in MDR-TB can become an MDR-TB expert after short course training. In medical school, you go for internship after completing five years medical training. This applies to this short course trainings.” CMEs should participate in the mentorship program in all health facilities, although this is hindered by extreme shortage of staff. For example, some staff had no colleagues to mentor in health centers and dispensaries. In terms of services, there are trained mentors and consultants, but the main challenge affecting mentorship in the NEP region is the very high staff turnover rates. Supportive mentorship and supervision as part of the trainings of FUNZOKenya is paramount.

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Mentorship guidelines Mentorship guidelines exist for the following services trained by FUNZOKenya: EMOC, EMNC, ART, and PMTCT. The different types of mentorship guidelines include booklets for reference and posters for display and most of them needed review. Some of the guidelines are stored in the different resource centers. In South Rift, NASCOP has a mentorship training that runs for six days. The trainees are assigned to mentors in the different departments after which they carry out a pre and post assessment and are certified. Mentorship at the facility level is still a challenge due to lack of a clear mentorship structure. Communication and coordination From the discussions, it emerged that organizing various participants for training from various facilities needs ample time to allow in-charges to allocate duties while staff are participating in trainings. It was further stated that early communication regarding training should be enhanced. “At least one week is required for relaying information about the availability of training for purposes of proper preparation for the training” (FGD participant). There is need for proper networking in terms of referral of patients. It was reported by the participants that communications and consultations exist and that aided with information sharing between health caregivers. In NEP region, the district health management team meetings are also part of interfacility communication alongside the provincial and county training committees and quarterly sharing meetings for sub county facilities. It was noted that some years before, radio calls helped in communication within the NEP region although it is no longer functional. Further, they stated information sharing should be done through regular CMEs within the health facilities. Interagency collaboration The teams proposed a need for synergy among various agencies to avoid duplication. The agencies implementing the trainings should have access to county strategic plans and integrated development plans. The partners should carry out a baseline survey of the needs of the county in collaboration with health management teams and address actual needs. Quarterly stakeholders meetings were proposed in order to discuss the development plans and address gaps in the service delivery to strengthen collaboration as well as provide a forum for report dissemination. ‘’There is need for partners to harmonize and understand what each is doing to avoid duplication, waste of resources and over emphasizing in some areas. This will create more impact in the community and effective service delivery’’ (FGD participant). It was also noted from the South Rift discussion that “Due to lack of support, the following sectors; public, private and NGO’s do not have interagency communication” (FGD Participant, South Rift). After the health organizations identify the needs and gaps, these should be further disseminated to the health facilities.

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Training curriculum ‘’Aspects of induction, attitude, decision making and leadership should be part of the curriculum that FUNZOKenya supports. This will make the trainings more effective and achieve the desired objectives,’’ (FGD Participant). Focus group discussions revealed a need for updating training curriculum. It was also reported that some trainers are providing varied protocols on the same service and thus confusing the participants. In North Eastern region for example, participants suggested that FUNZOKenya supports the incorporation of the harmonized HIV/AIDS curriculum in colleges and universities, which would allow for pre- service CMEs to acquire new skills before their facility placement, as opposed to after they are working. As part of the curriculum, the training should focus on more practical application and less on theories. There should be less power point presentations and more case study-based learning to improve skills. The curriculum and guidelines need to be reviewed and updated on a regular basis. It would be an added advantage to have preservice training with areas of specialization for the participants (e.g., specializing in midwifery according to one’s interest that was identified at the onset of the training). Coordination of training The study identified a gap in coordination of training. In Mombasa for instance, the FGD participants proposed that the trainings should be administered from within the service providers of the Health facilities as opposed to being led by general trainers from the county. Facility staff would offer trainings specifically tailored to patient population. Training logistics From the discussions, some of the staff would prefer half-board and dinner, rather than full-board accommodation, as was the case during the trainings. The participants observed the need to improve training packages as they were lower than what other training partners were offering. They also suggested that the choice of location of trainings need to be convenient for the trainees to minimize disruption of health service delivery in the regions. Trainers The team felt that there was need to train more trainers. In some instances, when key trainers are transferred, it leads to a critical scarcity of trainers in the respective regions. Focal person/ coordination It was proposed that a focal person be selected to play a key role in trainee identification, maintain the link between the facilities and training facilitators, and assist in setting up a follow-up mechanism.

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Certification and accreditation to offer service There are some health centers that do not have government regulatory agency’s approval to provide certain services. Despite having a trained staff member in the specific field, they cannot offer critical services without governmental certification. Placement and posting Health managers should be empowered to ensure that time is balanced between service provision and training attendance. Some staff members are trained on a specific course, but they cannot practice because their placement does not require the use of the skills or minimal relevance to the course. One example described was when, “A staff is trained in PMTCT and is deployed to mental health department” (FGD Participant). As a result, the trainees should be posted or placed in other areas that are relevant as per the training received. On-the-job training The teams suggested that on-the-job training should be enhanced in order to improve health service delivery. The facility in-charge should lead in organizing need-based on-the-job trainings, enabling clinicians to provide high quality service. Students from preservice training schools require a course in practical areas in addition to the provision of assigned mentors. Participants indicated that there was no other PTA conducted to identify the successes and challenges of the trainings as they related to service delivery.

Benefits of trainings support included:

The following benefits were cited as a result of the trainings; Improvement in infection prevention measures, data reporting and diagnosis outcomes for cervical cancer with improved referrals at critical points ,Confidentiality had improved in relation to PMTCT, services had been brought close to patients and are delivered on timely basis, new services offered, reduced referrals especially for ART, improvement confidence and skills after the training, Increase in Uptake of cervical cancer screening and family planning

Areas of Improvement

• There is a need for strict follow-up as this will increase the trainings success for the participants.

• MOH and other service delivery partners should collaborate and coordinate the training follow-up.

• Data should be utilized, analyzed, and disseminated to inform future decisions

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• The need for a patient exit interview/survey in evaluation of health service improvement since they are the beneficiaries.

• Need for a skills inventory, updated database for health workers trained and in which skills to easily identify staff requiring a specific training

• Invitations for training should go through the management as the appropriate channel in the health facility.

• Selection process should be based on facility needs and led by MOH. • Proper and timely communication between participants involved is important to

facilitate necessary follow up • The participants should be trained and assigned after the training for purposes of

mentoring. • Mentors should be assigned in every facility to allow for mentoring of the

trainees. • They should consider retraining of cervical cancer screening because the

confidence level of the trainees is low in the North Eastern region. • They should consider integration of training in courses offered at pre service

training institutes. • There is a need to address mechanisms of sustainability of the trainings. • There is a need to improve accountability for the trainings received. • The participants should provide feedback to the facility in-charges after training.

This will enable facility in-charges to allocate duties accordingly. • There has to be a mechanism identify and reward performers.

Barriers & Challenges to Service Provision by the Trainees

The barriers addressed in the discussion included: • Poor attitudes: It emerged during the discussions that poor attitude is a major

issue among staff and negatively affects the quality of health services. The health services should be client-centered and tailored. There is need for attitude change, especially given the merging of the two previously independent ministries, Ministry of Medical Services (MMS) and Ministry of Public Health and Sanitation (MOPHS).

• Internal wrangles • Lack of accountability • High staff turnover rates • Acute staff shortages • Poor infrastructure in terms of roads and communication networks • inadequate equipment and supplies • Lack of mentorship programs and facilitation • Cultural perspectives that hinder teachings and service delivery • Lack of feedback after the trainings • Commodity management: While HIV related services depend on donor funding,

and require reporting, some of the staff trained have no access to computers and internet connectivity, hence commodities for these services are managed and issued centrally at provincial and county/sub county level. This affected the use of skills trained in commodity management.

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• Poor documentation is also a challenge and leads to problems in quantification in terms of ordering of consumables in the facility

Summary Findings from Supervisor Interviews

Duties and Services offered by the supervisor The services offered by the supervisor in the facility included: administration, curative services, preventive, MCH services, consultative, coordination of services, enforcement of standards and ethics, preparing duty rosters, commodity management, report writing, mentorship and training, and supervision among others. Reason for change in provision of services by trainee The main reasons cited by trainees as contributing to positive change in the provision of services included: new skills and knowledge acquired, renewed commitment to work, increased competence, increased demand for services, change in attitude, facility starting to offer the service, availability of services and equipment and supportive supervision. Those who reported no change, cited lack or inadequate supplies and equipments, short time they had worked with the trainee , the trainee was not in the department where they could apply the skills, negative attitude towards service delivery, and poor uptake of the service by the community. Changes in quality of service delivery The reported change in terms of quality of service that included: improvement in patient safety, accuracy of diagnosis, client satisfaction, reduction in waiting time, improvement in record keeping, change of attitude of health providers, improved decision making, increased uptake of services, improved treatment outcomes, improvement in procurement of equipment and supplies, less referral, and improvement in patient confidentiality. Changes in quantity of service delivery Change in quantity of service delivery included: ability to attend to more patients in a shorter time, availability of commodities, increase service uptake, and increased frequency in service delivery, Forms of supportive supervision The forms of supportive supervision that exist include: APHIAPlus, CMEs, DASCO, DHMT, NASCOP, KEPHI, DMOH, DPHN, departmental supervision, institutional forums for sharing knowledge, monthly reports, staff appraisals, daily rounds, on-the- job trainings, seminars and working closely with supervisor. Available opportunities for continuing professional development The available opportunities for professional development for the trainee included: APHIAplus, FUNZOKenya, CMEs, on job training, seminars, eLearning, and distance learning courses, management training, and short courses.

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Comments on training that would improve service delivery in their respective facility The supervisors generally acknowledged the good work being done by the trainees after the trainings and recommended further training in other areas. Among the training s recommended for future consideration include malaria case management, IMAI, M&E, and CCC. They also recommended training of more staff in the facilities due to staff rotation and also provision of supplies and equipments to equip the trainee. Recommendations for improvement of the trainings Areas suggested for improvement in service delivery included: team work, mentorship, self-motivation, supportive supervision, and need for improved attitude.

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CHAPTER FOUR: DISCUSSION This section is an attempt to compare our findings with what is published on intent to transfer skills and knowledge.

Transfer of Training Training transfer means that learners are able to “transfer” their knowledge and skills learned in a training session back to their jobs effectively and continually, with an aim of improving performance. Goals of successful training transfer are that trainees generalize skills and that trainees maintain skills in the work setting. Training transfer is critical to ensure that learning is used to enhance performance (SHRH, 2013). Frameworks of Training Transfer Transfer is a multi-faceted process that involves activities and interventions throughout all phases of a training experience: pre, during and post-training. The training environment includes managers’ participation in the training, design of the training with adult-learning principles and instructional material in mind and development of learning goals. Under the Foxon model, organizational environment and action plans, formal coaching, uses of enabling technologies all affect employee performance (Foxon, 2002). In this study, it was found that eight out of every ten trainees were nurses and the trainees had experience of more than five years. Nine out of ten trainees were from public institutions and majority multi-tasked with 68 (24%) of trainees having reported to have changed their duty station after training. The facts above have a negative influence on transfer of skills from a learning environment to the workplace. Registered nurses have the responsibility of immunizations, out-patient service, in-patient service, under 5 examinations, school health, nutrition, and education (MOH, 2006). Nurses are able to multitask and this great advantage can be utilized in designing curriculum and on-the-job trainings with gender and experience in mind.

The Trainings A percentage of trainees had previously attended other trainings apart from those supported by FUNZOKenya. Surprisingly, some of the trainings were similar and attended within the same period August-December, 2012. The different ones were; basic life support, management of malaria, monitoring and evaluation (M&E), diabetes, and health management information. This calls for proper skills audit and planning to avoid duplication. There was an increase in frequency for all trainings, except EMNC, which recorded close to a 10% drop in attendance. The reason was not explored during the study as was how culture affected skill transfer. Staffing The WHO critical threshold for health personnel is 23 doctors, nurses and midwives per 10,000 population. Kenya remains at 13 per 10,000 (WHO, 2004). The 2004 staffing ratios for Kenya are doctors: 3 to 10,000 and nurses: 2 to 10,000 (WHO, 2006). Furthermore, Kenya is

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one of the 57 countries with an acute shortage of health workers. The health workers are skewed to urban areas (42% of doctors, 30% of nurses in the public sector are in Nairobi and Rift Valley Provinces while Western has 7% and 11% nurses). The objective of this study was not to determine adequacy or distribution of the health work force; however, it is public fact that the Health sector is short of staff. The timing, selection and criteria for selection is hence very important. The National HRH Strategic Plan 2009-2012 identified challenges involving the Kenyan human resource as inadequate distribution of health workers, high attrition, weak leadership and management capacity, weak in-service and pre-service training, and poor sectorial coordination of the HRH agenda among others. Development of adult training methodologies and eLearning, training and mentorship at workplace could address the challenges of staff shortages and improve staff performance results. A paper on relative efficiency of didactic (principle-based), learning via information revelation, analogical training and observational learning, imitation, or modeling found that those who learned by analogical and observational methods learnt better (Nadler, Thompson and Van, 2003).

Missing Respondents Fifty-four (19%) respondents were replaced. In future trainings, there is need to use a bottom-up approach where organizations have strategic objectives and skills inventory which then inform the selection of trainees, with clear deliverables to the workplace. Trainees would return to their work environment and implement organizational/institutional plans. Similarly, such employees may be bonded by the employer for some while as they apply the skills. A minimum period should be set before an employee applies for another course. There exists a guide on leave days and training days per cadre RCN(Registered Community Nurse 24 working days per month, 30 off trainings days, lab technologies 26.17 and 10 for training while pharmaceutical technologist are allowed 25.25 and 21 days respectively (MoH, 2006). This should be taken into consideration during trainee selection.

Public Health Facilities Health facility distribution is 21% FBO, 5% NGO, 60% public sector, and 14% private for profit. From the trainings however, 91% of trainees were from the public sector. This may be due to improper selection criteria, initial target of the public sector, or willingness of public sector employees/ employers to learn. A county skills inventory and human resource plan would be ideal for all the counties in Kenya as part of harmonized human resource planning.

Accreditation of Facilities Some of the trainees were selected from health facilities not accredited to provide the specific health services. This meant that the trainees would not be able to practice that skill upon their return. Amongst the results reported, 45% of staff are in locations not directly related to the service for which they were trained, 40% had low case loads, 26% had the services not provided by the facility.

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Inhibiting and Supporting Factors Framework

Figure 5: Supporting and Inhibiting Factors for Intention to Transfer, adapted from

Foxon, 2002

Factors that influence transfer of skills include organizational climate, training content, learner motivation, internalization of transfer strategies, support supervision and follow-up, and ability to apply what was learnt. Baldwin and Ford (1988) first proposed a three-factor model of transfer. Later, Burke and Hutchins (2007) conducted an integrative review of literature that updated and extended the transfer model.

Figure 6: Three-factor model of transfer

Adapted from Burke and Hutchins (2007)

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In this model, several factors affect both learning and transfer of knowledge and skills from a training. Transfer is also not the end result; successful transfer ultimately leads to improved individual and organizational performance hence meeting the individual, workplace, and overall organizational plans and sector-wide plans. Supportive Supervision and Mentorship Proper supervision and follow up ensures that healthcare workers can implement the lessons learned during the initial training sessions. It focuses on improving conditions required for proper functioning of the health delivery system. Mentorship on the other hand aims at improving skills of trained service providers to offer quality services (MOH, 2012). The finding in this study was that trainees should undergo refresher courses in areas of specialization, and that each facility should have a mentor. Drawing from the seminal work of Baldwin and Ford (1988), who first proposed a three-factor model of transfer, Burke and Hutchins (2007), conducted an integrated review of literature that updated and extended the transfer model. Emerging research shows that the work environment has a strong influence on learners’ use and maintenance of learning in the work setting. Supporting transfer at the learner, design and work environment levels requires developing interventions that occur throughout (before, during, after) the training experience (SHRM, 2013).

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CHAPTER FIVE: CONCLUSIONS AND RECOMMENDATIONS The PTA exercise, carried out approximately one year after training 1,662 health workers, was designed to investigate the extent to which, if any: the acquired skills and knowledge have been applied to the workplace, whether there had been change in quality or quantity of health service delivery, and inhibiting or supporting factors that may have contributed to the changes. There was a significant increase in variety and quantity of all services provided following training (63% offered the services before compared with 88% who offered the service after training) with the exception of EMNC. Measurement of quality of service delivery was difficult in this design where the client was not interviewed. The perception was that quality of service had improved as evidenced by improvement in service uptake, improved patient safety, decreased waiting time, and attitude change. Several factors contributed to the improved service delivery uptake, the top five being level of confidence acquired and the knowledge and skills gained. However, incorrect placement following trainings and high staff turnover were cited as inhibitors to proper service delivery. Findings that identified over 90% of trainees having been sourced from public facilities could be due to the initial focus; health workers from public facilities but that contradicted the National Coordinating Agency for population and development (NCAPD) which reported that 60% of the facilities are public while 21%, 14%, and 5% are FBO, private for profit, and NGOs respectively. Several trainees identified lack of an organized mentorship program despite that fact that over 85% had supportive supervision. Trainee selection and the need for a focal point are critical to monitoring the trainings and increasing accountability. Staff shortage needs to be addressed during participant selection and staffs’ ability to multitask especially during trainings. A transfer matrix tool that details the role of trainers, trainees and supervisors before, during and after the training as below may be used to increase organization, sustainability and ensure success (Appendix 9).

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RECOMMENDATIONS Policy There is need to develop HR training policy that covers selection criteria of trainees, training needs, the workload of the service provider, number of trainings during that period, monitoring and supportive supervision. The role of county governments’ health sector should also be clearly identified. Program

1. Identify health sector focal person, preferably at the county health directors’ office and national levels to be liaison for trainings.

2. Examine trainee needs, taking into consideration personal comfort of trainees, timely invitation, and flexible logistic arrangements.

3. Develop trainee follow-up mechanism for accountability and support 4. Improve the workplace environment including supplies, equipment, and

infrastructure. 5. There is need to development of adult friendly training materials and curriculum

delivery especially e-Learning updates that allow one to train at work with special focus to resource-challenged counties.

6. Develop curriculum for other courses based on needs like malaria, induction, attitude, leadership, etc.

Work-place Community

1. Encourage formal coaching: develop individual, departmental and institutional action plans, employee performance agreements and support.

2. Link training to organizational goals and potential application of the trainings Further Research

1. Revise the curriculum adopting innovative adult teaching methodologies 2. Impact of FUNZOKenya supported trainings on skill transfer at workplace 3. Investigate loss to follow-up of service providers, and influence of culture on skill

transfer.

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REFERENCES

Baldwin, T.T., & Ford, K.J. (1988). Transfer of training: A review and directions for future research. Personnel Psychology, 41, 63-105 (http://www.performancexpress.org/wp-content/uploads/2011/11/Transfer-of-Training.pdf) Accessed on 5th November 2013. Broad, M. L., & Newstrom, J. W. (1992). Transfer of training: Action-packed strategies to ensure high payoff from training investments. Reading, MA: Addison-Wesley Broad, M.L. (2005). Beyond transfer of training: Engaging systems to improve performance. San Francisco, CA: John. Wiley & Sons Buchan, J., Carnwell R., (Eds) (2005). Effective practice in Health and Social Care: A partnership approach. Sage Publications Burke L.A., Hutchins H.M., (2007). Transfer of Training. Society for Human Resource Management Burke, L.A., & Hutchins, H.M. (2007). Training transfer: An integrative literature review and implications for future research. Human Resource Development Review, 6(3), 263-296. Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M (2004). Human resources for health: overcoming the crisis. Lancet, 364: 1984–1990. Available: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)17482-5/fulltext (Last accessed on 1st November, 2013).

Dielman M., Harnmeijer J. (2006). Improving health worker performance: In search of promising practices. Royal Tropical Institute: The Netherlands. Foxon M. (2002). A process approach to the transfer of training. Part 2: Using action planning to facilitate the transfer of training. http://www.shrm.org (Accessed on 9th November, 2013). IntraHealth and Jhpiego (2002). Transfer of Learning: a guide for strengthening the performance of health care workers. Chapel Hill NC: PRIME II Project. Available http://www.intrahealth.org/page/transfer-of-learning-a-guide-for-strengthening-the-performance-of-health-care-workers- Personnel Psychology, 41. Joint Learning Initiative (2004). Human resources for health: overcoming the crisis. Boston: Harvard University. Available: http://www.who.int/hrh/documents/JLi_hrh_report.pdf (Accessed on 9th November, 2013). Ministry of Health (2006). Guidelines on mentorship for HIV services in Kenya, NASCOP Ministry of Health (2006). Norms and Standards for health service Delivery

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Ministry of Medical Services and Ministry of Public Health and Sanitation. The Kenya Health Sector Strategic and Investment Plan – KHSSP July 2013 – June 2017. Nadler, Thompson and Van (2003), Knowledge creation and transfer in negotiation, Management science Vol.49, No.4 April, pp 529-540 Olawiyola LM, Adelaye OA. (2005). Rural infrastructural development in Nigeria; between 1960-1990-Problems and Challenges; Journal of Social Sciences, 2004; Vol 94; No 11; pages 91-96 The Kenya National HRH strategic plan 2009-12 The Kenya National Human Resource for Health Strategic Plan 2009-2012 World Health Organization (2004). Atlas of Global work Force. WHO, Geneva World Health Organization (2006). The world health report 2006: working together for health. Geneva: WHO. Available: http://www.who.int/whr/2006/en/ (Accessed on 9th November, 2013) World Health Organization (2007). Montreux Challenge: Making health systems work. WHO, Geneva.

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APPENDICES

APPENDIX 1- CONSENT FORM RA Code: ___________ Informed Consent Hello, my name is _____________. I work for Moi University College of Health Sciences and a member of the post training follow-up assessment team who has been identified by MOH-Human Resource Department and Department of Standards and Regulations with support from FUNZOKenya to carry the post training follow up on their behalf. The training in question was sponsored by FUNZOKenya. We request your participation in this follow-up assessment. The purpose of this training follow-up activity is to learn how you have integrated the training knowledge and skills in your job performance. The objectives are to determine:

1. The extent to which you have been able to apply their new skills on the job 2. Whether application of learning in the context of work has resulted in a change in the

quality or quantity of services offered 3. Any factors limiting the use of new skills on the job

I would like to ask you about how relevant and applicable you have found the training and materials now that you have returned to your workplace. We are conducting similar interviews with other participants from the workshop. We will use the information to determine how successful the training was, which training elements were most relevant and applicable, and what additional training and other support is needed to apply what you learned. If you agree, you will be among the 300 trainees that will participate in this survey. Your participation in this follow-up is voluntary and there is no penalty for refusing to take part. You may refuse to answer any question in the interview or stop the interview at any time without any adverse consequences.

The information you provide will be confidential and your name will not be identifiable by any unauthorized persons outside the research team. Any reports of the results of the follow-up will not contain your name. There is no financial compensation or other personal benefits from participating in this follow-up assessment. However, the information may be used to influence Health policy and any other beneficial attributes to humanity.

There are no known risks to you or your institution resulting from your participation in the follow-up. If you agree to participate, the interview will take about 30 minutes to complete.

In case you have any enquiry to make or clarification, you may contact:

The Principal College of Health Sciences or MECC Building 3rd Floor Nandi Road P.O Box 4606, 30100 Eldoret. Email: muchs@ac.ke Tel 254 726 593141(Dr Simiyu)

Head-HRD Ministry of Health (MOH), AFYA House, Cathedral Road Box 30016 Nairobi Tel : 254-020-2717077

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Do you agree to participate? Yes ____ No ____ Not Available _______

Signature: _______________________________ Date: ________________________

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APPENDIX 2- TRAINING FOLLOW-UP PARTICIPANT’S QUESTIONNAIRE

(TO BE COMPLETED BY THE SERVICE PROVIDER WHO ATTENDED TRAINING)

Part A Demographic Data: 1. Participant’s Code:______________________________ Health facility Name:

_________________________________ County: ___________________________________________

2. Name of training assessed for: (RA to complete) __________________________________________________

3. Training dates: Start date: ________/_________/________ End Date:

________/_________/_________

4. Gender(Tick/Circle): M [ ] F [ ]

5. DOB : ________/_________/______________ or Age in years:_________________________________

6. Cadre (e.g Nurse, Medical officer, Clinical Officer, Nutritionist etc.): _________

7. Designated Role (Administrative) if ANY: _____________________________________________________________

8. Highest Education status: [ ] Basic Degree Year: ___________________ [ ] Post graduate Diploma Year: ___________________ [ ] Diploma Year: ___________________ [ ] Certificate Year: ___________________ [ ] Other: _______________________ Year: ___________________ 9. For how many years have you been in service (as a healthcare provider): [ ] <1 [ ] 1-3 [ ] >3-5 [ ] >5 10. Type of Facility/Institution [ ] Public [ ] Private [ ] FBO [ ] NGO 11. In which section/ service area/department were/are you working?

DD MM YYYY DD MM YYYY

DD MM YYYY

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At the time of training

Currently Note: NC=No Change, C=Changed

Section/Department/service area

12. What is your duty in this station? (RA to probe)

___________________________________________________________________________________________________________________________________________________________________________________________________________

13. List previous short course training/s attended in the last 3 years and their duration: # Name of the course Duration (Weeks)

Part B Service Delivery:

14. What in-service training(s) did you undertake with support from FUNZOKenya.(Aug-Dec 2012)

# Training Title

Tick (√) #

Tick (√)

1 Pediatric ART Management

8

Commodity Management

2 PMTCT 9 MDR-TB

3 Adult ART Management 1

0 IMCI

4 LAPM-FP 1

1 EMNC

5 Cervical Cancer Screening

12

Gender Based Violence (GBV)/Clinical Management of Sexual Violence

6 EMOC 1

3 Others (specify

7 FANC

15. Were you offering these services before your training? [ ] Yes [ ] No

16. (A) If yes, what services were you offering?

________________________________________________________________________________________________________

16. (B) If no, what are the reasons? (Skip to Q18) ________________________________________________________________________________________________________

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17. (A) On a scale of 1 – 6, to what extent were you offering this service before training? 1=Offers the service everyday of the week, 2= Offers the service 3-4 days in a week, 3= Offers the service 2 days in a week, 4= Offers the service once in a week, 5= Offers the service only occasionally & 6= Never

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# Type of service

Frequency (code)

# Type of service

Frequency (code)

1 Pediatric ART Management

8 Commodity Management

2 PMTCT 9 MDR-TB

3 Adult ART Management 1

0 IMCI

4 LAPM-FP 1

1 EMNC

5 Cervical Cancer Screening

12

Gender Based Violence (GBV)/Clinical Management of Sexual Violence

6 EMOC 1

3 Others (specify

7 FANC 17. (B) RA to probe on reasons for the frequency if they are health facility determined:

________________________________________________________________________________________________________________________________________________________________________________________________________________

17. (C) Before you went for training how many patients were you seeing per month (Jan- June 2012)?

________________________________________________________________________________________________________

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18. After training are you offering this/these service(s) now? □ Yes □ No .If no skip to question 22

# Type of service

Tick (√)

# Type of service

Tick (√)

1 Pediatric ART Management

8 Commodity Management

2 PMTCT 9 MDR-TB

3 Adult ART Management

10 IMCI

4 LAPM-FP 1

1 EMNC

5 Cervical Cancer Screening

12

Gender Based Violence (GBV)/Clinical Management of Sexual Violence

6 EMOC 1

3 Others (specify

7 FANC

19. (A) On a scale of 1 – 6, to what extent are you offering this service – post training?

1=Offers the service everyday of the week, 2= Offers the service 3-4 days in a week, 3= Offers the service 2 days in a week, 4= Offers the service once in a week, 5= Offers the service only occasionally & 6= Never

# Type of service

Frequency (code)

# Type of service

Frequency (code)

1 Pediatric ART Management

8 Commodity Management

2 PMTCT 9 MDR-TB

3 Adult ART Management

10 IMCI

4 LAPM-FP 1

1 EMNC

5 Cervical Cancer Screening

12

Gender Based Violence (GBV)/Clinical Management of Sexual Violence

6 EMOC 1

3 Others (specify

7 FANC 19. (B) RA to probe on reasons for the frequency if they are health facility determined:

___________________________________________________________________________________________________________________________________________________________________________________________________________

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19. (C) After you went for training how many patients are you seeing per month (Jan- June 2013)? ___________________________________________________________________________________________________________________________________ 20. What challenges are you experiencing in service delivery (tick all that apply)

[ ] Lack of confidence in skills [ ] Service procedure-trained-in is not provided in the facility [ ] Current position not relevant to the service procedure [ ] Stock out of supplies/equipment/instruments [ ] Low demand/low client caseload [ ] Lack of clear job description [ ] Lack of clear and immediate feedback from supervisors [ ] Inadequate physical environment including proper tools, supplies and workspace [ ] lack of motivation and incentives to perform as expected [ ] Lack of skills and knowledge required to do the job [ ] Staff rotation/movement to different section/ facility [ ] Culture/religion [ ] Others (Please specify):________________________________________________________________________________________________________________________________________

21. What factors have enabled you to improve service provision after the training? [ ] Increase in the level of confidence in skills [ ] Service procedure-trained-in now provided in the facility [ ] Current position relevant to the service procedure [ ] Availability of supplies/equipment/instruments [ ] High demand for the services [ ] Feedback from supervisors [ ] Appraisal and incentives to perform as expected [ ] Acquisition of skills and knowledge required to do the job [ ] Others (Please specify) _________________________________________________________________________________________________________________________________________

22. If no in Q18, what difficulties prevented service provision despite you being trained? (Tick all that apply). [ ] Lack of confidence in skills [ ] Service procedure-trained-in is not provided in the facility [ ] Current position not relevant to the service procedure [ ] Stock out of supplies/equipment/instruments [ ] Low demand/low client caseload [ ] Lack of clear job description [ ] Lack of clear and immediate feedback from supervisors [ ] Inadequate physical environment including proper tools, supplies and workspace [ ] lack of motivation and incentives to perform as expected [ ] Lack of skills and knowledge required to do the job [ ] Staff rotation/movement to different section/ site/ facility

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[ ] Others (Please specify) ________________________________________________________________________

23. What improvements have you made in service delivery, if any, as a result of this training? (Interviewer to probe using a checklist & respondent to demonstrate improvement) Type of training Services improved/introduced Score

24. In the discharge of your duties do you have access to resources that facilitate

provision of service delivery that you trained for? Need a checklist of resources for all the 5

Resources If Yes, proceed to scale

In a scale of 1-4, rate the availability of the above resources (Tick)

Yes No Poor Moderate Good Excellent

1 Physical (Space, rooms)

2 Human

3 Financial

4 Materials (Consumables)

5 Equipments

25. What other resources apart from the ones mentioned above do you need to

execute your functions? ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Part C Mentorship and Supervision: 26. Have you ever been mentored since the training (the current training being assessed

on)? [ ] Yes [ ] No

27. If No, what is the reason? (Tick all that apply)

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[ ] No mentorship programme in place [ ] Unavailability of mentors [ ] Shortage of time [ ] Lack mentorship guideline [ ] Not aware of anything called mentorship [ ] Others (Please specify) _____________________________________________________________________________________________________________________________________________________

28. Since the training, are you mentoring anybody? [ ] Yes [ ] No

29. Are there any other forms of supportive supervision, beneficial to continuing professional development? [ ] Yes [ ] No If yes, please specify: ___________________________________________________________________________________

Part D Training Recommendations:

30. What aspect of training has been useful in the place of work?

________________________________________________________________________________________________________________________________________________________________________________________________________________________

31. What aspects of training need improvement? ________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________

32. What other training if any would you require in order to improve service delivery in the

facility? ____________________________________________________________________________________________________________

33. Would you recommend this training to other service providers?

________________________________________________________________________________________________________________________________________________________________________________________________________________________

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APPENDIX 3- POST TRAINING FOLLOW-UP SUPERVISOR’S QUESTIONNAIRE Part A Demographic Data:

1. Supervisor’s Code: _______________________________________ 2. Gender: M [ ] F [ ] 3. DOB: ________/_________/______________ or Age in years____________________ 4. Cadre (e.g. Nurse, Medical officer, Clinical Officer, Nutritionist etc):

________________________________ 5. Designated Role (Administrative) if ANY:

______________________________________________ 6. Highest Education status:

[ ] Basic Degree Year: ___________________ [ ] Post graduate Diploma Year: ___________________ [ ] Diploma Year: ___________________ [ ] Certificate Year: ___________________ [ ] Other: ______________________ Year: ___________________

7. For how many years have you been in service (as a healthcare provider): [ ] <1 [ ] 1-3 [ ] >3-5 [ ] >5

8. Type of Facility/Institution [ ] Public [ ] Private [ ] FBO [ ] NGO

9. What is the level of this health facility? Name of facility:________________________________ [ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6

10. Type of services Offered by the facility (for the institutional head) __________________________________________________________________________________________________________________________________________________________________________________________________________________

11. In which section/service area/department were/are you working?

At the time of training

Currently Note: NC=N Change, C=Changed

Section/Department/service area

Part B Training and Service Provision:

DD MM YYYY

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12. What is your duty in this station? (RA to probe) __________________________________________________________________________________________________________________________________________________________________________________________________________________

13. For how many years have you worked with the trainee [ ] Less than a year [ ] 1-2 years [ ] >2—3 years [ ] More than 3 years

14. What training did the above mentioned service provider receive from FUNZOKenya.(Aug-Dec 2012)

# Training Title

Tick (√) #

Tick (√)

1 Pediatric ART Management

8 Commodity Management

2 PMTCT 9 MDR-TB

3 Adult ART Management

10 IMCI

4 LAPM-FP 11 EMNC

5 Cervical Cancer Screening

12

Gender Based Violence (GBV)/Clinical Management of Sexual Violence

6 EMOC 13 Others (specify

7 FANC 14 Don’t know

15. Did the trainee provide feedback to the facility after the training? [ ] Yes [ ] No [ ] don’t know

16. What are the services offered by this trainee # Type of Service

Tick (√) # Type of Service

Tick (√)

1 Pediatric ART Management

8 Commodity Management

2 PMTCT 9 MDR-TB

3 Adult ART Management

10 IMCI

4 LAPM-FP 11 EMNC

5 Cervical Cancer Screening

12

Gender Based Violence (GBV)/Clinical Management of Sexual Violence

6 EMOC 13 Others (specify

7 FANC

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17. On a scale of 1 – 6, how often are these services offered? 1=Offers the service everyday of the week, 2= Offers the service 3-4 days in a week, 3= Offers the service 2 days in a week, 4= Offers the service once in a week, 5= Offers the service only occasionally & 6= Never offered any service

# Type of service

Frequency (code)

# Type of service

Frequency (code)

1 Pediatric ART Management

8 Commodity Management

2 PMTCT 9 MDR-TB

3 Adult ART Management

10 IMCI

4 LAPM-FP 11 EMNC

5 Cervical Cancer Screening

12

Gender Based Violence (GBV)/Clinical Management of Sexual Violence

6 EMOC 13 Others (specify

7 FANC

18. On a 5 point scale, to what extent has training of this health worker changed service provision in the facility [1] Negative Change

[2] No Change

[3] Some Change

[4] A lot of Change

[5] Excellent change

19. What do you think are the reasons for this change: (list common reasons)

____________________________________________________________________________ 20. What factors have enabled the trainee to improve service provision after the

training? [ ] increase in the level of confidence in skills [ ] Service procedure-trained-in now provided in the facility [ ] Current position relevant to the service procedure [ ] Availability of supplies/equipment/instruments [ ] High demand for the services [ ] Feedback from supervisors [ ] Appraisal and incentives to perform as expected [ ] Acquisition of skills and knowledge required to do the job[ ] Others (Please specify) ______________________________________________________________________________

21. How often is the trainee willing to offer the above services (in question 17) [ ] Always [ ] Often [ ] Sometimes [ ] Not at all

22. If not offering service in Q17, what reason (s) prevented service provision by this trained service provider (Check all that apply). [ ] Lack of confidence in skills [ ] Service procedure-trained-in is not provided in the facility

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[ ] Provider not in a job position to provide the service procedure [ ] Lack of demand/clients [ ] Lack of supplies/equipment/instruments [ ] Other service system barriers (e.g. lack of operating room time, lack of support staff) [ ] Lack of clear job description [ ] Lack of clear and immediate feedback from supervisors [ ] inadequate physical environment including proper tools, supplies and workspace [ ] lack of motivation and incentives to perform as expected [ ] Lack of skills and knowledge required to do the job [ ] Staff rotation/movement to different section/ Site/ facility [ ] Others (specify) ____________________________________________________________________________

23. (A) Has the training brought any improvement on the service delivery by the service provider

[ ] Yes [ ] No (B) What improvements, if any, in the quality or quantity of services have been

made in the facility as a result of the training received by the service provider? a. Quality (Turnaround time, patient safety, client satisfaction, procurement

of equipment, improved, reporting, treatment outcomes, service protocol improvement, accuracy of diagnosis, improved decision making etc):

b. Quantity ( Service uptake, frequency of service delivery, availability of commodities etc) :

___________________________________________________________________________________________________________

24. Has the trainee mentored other service provider (s), since the training (based on the training being assessed on) [ ] Yes [ ] No [ ] don’t know

25. If No, what is the reason? (Tick all that apply) [ ] No mentorship programme in place [ ] Unavailability of mentee [ ] Shortage of time [ ] Lack mentorship guideline [ ] Not aware of anything called mentorship [ ] Others (Please specify) ______________________________________________________

26. Are there any other forms of supportive supervision? [ ] Yes [ ] No If yes, please specify: ____________________________________________________________________________________

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27. Are there opportunities for continuing professional development for the trainees? [ ] Yes [ ] No If yes, please specify: ____________________________________________________________________________________

28. What other comments do you have related to this service provider and training received? Include comments on training that would improve service delivery in your facility?

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APPENDIX 4: POST TRAINING FOLLOW-UP CHECKLIST Applicable to all trainings (For Participants interviews) - Maximum Score (20)

Standard Requirements

Score 0 1 2 3 4 5

Patient charter No Yes Sops and guidelines for treatment and screening

No Yes

Availability of commodities (Drugs, gloves, test kits )

None Sometimes Most of the time

Always

Record keeping Monthly reports Completeness Tools MOH

Not available

Available

No Yes Not available

Available

Equipment Available Preventive maintenance Record Adequacy Functional

No Yes No

Yes

No Yes No Yes

IEC Materials Availability

No Yes

% Changes in service uptake (Registered clients)

No Change

1-10 11-20 21-30 31-40 >40

Customer satisfaction (Suggestion box)

No Yes

Signage/Directions to service areas

No Yes

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APPENDIX 5- POST TRAINING FOLLOW-UP GUIDE FOR FOCUSED GROUP DISCUSSION (FGD) Dear Members, You are welcome to this forum. We are a team from Moi University College of Health Sciences and members of the post training follow-up assessment, who have been identified by MOH-Human Resource Department and Department of Standards and Regulations with support from FUNZOKenya to carry the post training follow up on their behalf. The training in question was sponsored by FUNZOKenya. We shall then introduce ourselves by name. We would like to introduce yourself by stating:

Your name, facility you belong, level of facility & services offered by your facility. The purpose of this training follow-up activity is to learn how the knowledge and skills acquired by the trainees have been integrated in their job performance. The objectives are to determine:

1. The extent to which they have been able to apply the new skills on the job 2. Whether application of learning in the context of work has resulted in a

change in the quality or quantity of services offered 3. Any factors limiting the use of new skills on the job

We would like to ask you whether there are any challenges the trainees may be experiencing after the training. We are conducting similar interviews with other participants from the workshop and their immediate current supervisors. We will use the information to determine how successful the training was, which training elements were most relevant and applicable, and what additional training and other support is needed for the trainee to apply what they learned. Your participation in this FGD is voluntary and there is no penalty for refusing to take part. You may refuse to answer any question in the FGD or stop the discussion at any time without any adverse consequences. The information you provide will be confidential and your name will not be identifiable by any unauthorized persons outside the research team. Any reports of the results of the follow-up will not contain your name. There is no financial compensation or other personal benefits from participating in the FGD. However, the information may be used to influence Health policy and any other beneficial attributes to humanity. There are no known risks to you or your institution resulting from your participation in the FGD. This discussion will take slightly more than one (1) hour and may involve video recording of the discussion process. In case you have any enquiry to make or clarification, you may contact:

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The Principal College of Health Sciences or MECC Building 3rd Floor Nandi Road P.O Box 4606, 30100 Eldoret. Email: muchs@ac.ke

Head HRD Ministry of Health AFYA House, Cathedral road, Box 30016, Tel :+254-020-2717077 Nairobi, Kenya.

You are free to express any questions and concerns before we begin.

TRAINING FOLLOW-UP GUIDE FOR FOCUSED GROUP DISCUSSION (FGD)

Date: ________/_________/____________

Start Time: _______________________

End Time _________________________

Question Guide:

1. Kindly remind us in which county we are holding our meeting? 2. How many health facilities are in this region? 3. Are there resources for the following services? (probe in each resource using a

checklist)

1 Pediatric ART Management 8 Commodity Management

2 PMTCT 9 MDR-TB 3 Adult ART Management 10 IMCI 4 LAPM-FP 11 EMNC – essential maternal & new born care

5 Cervical Cancer Screening 12 Gender Based Violence (GBV)/Clinical Management of Sexual Violence

6 EMOC – Emergency Obstetrics Care 13 Others (specify

7 FANC – Focused Antenatal Care

4. Within the last ONE YEAR, has there been any FUNZOKenya sponsored training in

this region? If yes, what has been the kind of training?

5. If yes, how have your facilities/organization benefited from the trainings?

6. Following the training, what is your view on quality of service by the trainees in this region (probe using the following parameters: Patient safety, Effectiveness of health care, Patient – centeredness, Knowledge & Skills of trainee, Timeliness of health service, Efficiency of health care, Equity of health care.

7. What are barrier to the service provision by the trainee (s) after the training?

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8. What are the mentorship guidelines available in the health facilities within the region?

9. Kindly describe to us the forums that exist for interfacility/interagency communication?

10. Do you have suggestions on how in-service trainings can be improved in the future?

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APPENDIX 6: RESEARCH ASSISTANTS Gender Male 11 Female 10

1. Caroline Magut South Rift 2. Sherine Adipo South Rift 3. Kevin Kibet Langat South Rift 4. Joyce Kisiangani South Rift 5. Alfred Koskei Coast 6. Cynthia Achieng Coast 7. Japheth Ruto Coast 8. Esther Jebiwott Coast 9. Moses Wakuloba North Eastern Province 10. William Kemei North Eastern Province 11. Tabitha Chepkemoi Central 12. Joseph Ndungu Central 13. David Langat Nairobi 14. Christopher Wandabwa Nairobi 15. David Kibet Western 16. Scholastica Jemutai Western 17. Zipporah Metto Western 18. Jecinta Mutua Machakos 19. Joyline Jepkosgei Machakos 20. Douglas Ngugi Embu & Meru 21. Elias Kipchirchir Embu & Meru

APPENDIX 7: ADVISORY GROUP 1. Professor FO Esamai 2. Prof Sylvester Kimaiyo 3. Prof W Nyandiko 4. Prof L Diero 5. Prof P Gatongi

APPENDIX 8: SECRETARIAT 1. Andrew Busienei - Logistics 2. Joseph Kipkoech - Logistics Team Leader 3. Dr. Ann Mwangi - Data Team Leader 4. Edwin Sang - Data- Quantitative 5. Dr. Simiyu Tabu - Project Team Leader 6. Eunice Walumbe - Data-Qualitative 7. Jepchirchir Kiplagat - Data-Qualitative

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APPENDIX 9: Transfer Matrix and Trainee Support Framework Before During After

Trainers

Trainees

Supervisors

Training Environment

Work environment

Modified from Broad (2005)

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APPENDIX 10: Muchs-FUNZOKenya Post-training Assessment Schedule

Activity Modified dates Participants FUNZOKenya Pre-Visit Moi University

July 31st 2013 MUCHS & FUNZOKenya team

MUCHS Consultative meeting

July 31st,2013 MUCHS Advisory

Technical Meeting August 5th,2013, at the Noble

MUCH Technical Team

Technical Meeting August, 6th 2013 MUCHS Technical Team Submission of proposed changes to the tool COP

August 9th ,2013 MUCHS Technical Team

Consultative meeting August 19th ,2013 MUCHS and FUNZOKenya Stakeholders meeting(as per model)

August 20th ,2013 Various

Internally advertise and Recruit

September 16th - Interviews

MUCHS logistics

Training 20th September MUCHS Technical Team Piloting of the tool 23rd September MUCHS Technical Team Tool Review and Enhancement

24-25 September MUCHS Team

Logistics to Sites 26th – 27th September MUCHS Team Travel to Sites 28th – 29th September MUCHS Team Data collection 30th Sept – 11th October MUCHS with Support of

stakeholder Travel Back from Sites 12th – 13th October Data Entry, Cleaning and Analysis

14th – 19th October MUCHS

Data Entry, Cleaning and Analysis

MUCHS and technical team

Report Writing & Preliminary findings

21st – 31st October MUCHS Technical Team(6)

Draft Report Presentation 4th November Dissemination to stakeholders

5th November MUCHS Technical Team led by AMPATH COP and Principal(7)

Final Report 18th November MUCHS Technical Team

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APPENDIX 11: Letter from the Human Resources Department, MOH