Background
Located in the western part of Kenya, Bungoma County is one of the 47 devolved governments established under the 2010 Kenyan Constitution. The county, according to the 2019 Kenya Population and Housing Census, is home to 1,670,570 people, with a nearly equal gender distribution (51% female, 49% male) and a population growth rate of 2.1%. The county is administratively divided into nine sub-counties and has 269 functional health facilities, with 154 being government-operated.
Bungoma has made significant strides in maternal and child health, as evidenced by key indicators: 98.6% of pregnant women receive antenatal care from skilled providers, 72.5% attend more than four ANC visits, and 87.2% deliver by skilled labor. However, challenges remain, with perinatal mortality at 28% and under-five mortality at 55% (KHIS, 2022).
- Four+ ANC visits: 72.5%
- Skilled delivery: 87.2%
- Perinatal mortality: 28%
- Under-five mortality: 55%
In 2014, Kenya’s Ministry of Health (MoH), with support from ALMA and partners including UNICEF, WHO, Measure Evaluation, and USAID, developed the national the Reproductive Maternal New-born Child and Adolescent Health (RMNCAH) Scorecard, subsequently rolling it out to all 47 counties and building county capacity for its use.
Bungoma County began implementing the RMNCAH Scorecard in late 2017. Within two years, the county had successfully decentralised the scorecard’s review and utilisation down to the sub-county, ward, and health facility levels, including in Kabuchai Sub-County.
Utilisation of the RMNCAH Scorecard
I strongly recommend that as many managers as possible access, understand, and use the scorecard. It simplifies decision-making.
Francis Kagode – Health Records Officer, Kabuchai Sub-County
Francis Kagode, the Sub-County Health Records Officer in Kabuchai Sub-County, reflects on the impact of the RMNCAH Scorecard. “Before we had the scorecard, we often worked until the end of the year, only to realise during the Annual Workplan review that we were not performing well in some areas. Now, with the RMNCAH scorecard, we can track our progress consistently,” Francis shares.
As a Health Records Officer with six years of experience, Francis’s role is critical. He is responsible for collecting, compiling, and sharing performance data, guiding the Sub- County Health Management Team on strengths and areas needing improvement. The RMNCAH scorecard provides a comprehensive view of critical indicators such as skilled delivery rates, antenatal and postnatal care coverage, and full child immunisation rates among others.
“The scorecard is not just a tool; it’s a catalyst for action. For instance, in Q4 of 2023, we identified low immunisation coverage in Kabuchai Sub-County. By sharing this data with the Sub-County Public Health Nurse, we initiated a targeted intervention that improved our immunisation rates (FIC) from 58% to 63% in Q2 2024,” Francis explains.
The scorecard’s user-friendly design, and color-coded indicators performance, allows for quick assessment of performance and facilitates informed decision-making. “I strongly recommend that as many managers as possible access, understand, and use the scorecard. It simplifies decision-making,” Francis reiterates.
- A catalyst: The RMNCAH scorecard is not just a tool; it is a catalyst for action.
- Simplicity: Color-coded indicators performance, allows for quick assessment of performance and facilitates informed decision-making
Case study 1: Enhancing immunisation coverage in Kabuchai Sub-County, Bungoma County
Kabuchai Sub-County, located within Bungoma County, Kenya, has 21 health units, 17 of which are primarily supported for vaccination services. The sub-county, like the broader Bungoma region, faces challenges in meeting its immunisation targets, which are set at 100%. Key obstacles include logistical issues, staffing shortages, and community misconceptions about vaccination schedules. Despite these challenges, efforts are being made to improve immunisation coverage through the use of the RMNCAH scorecard.
Caroline Lukando, the Sub-County Public Health Nurse, plays a crucial role in overseeing immunisation services in Kabuchai. Her responsibilities include ensuring that these services are up and running, managing logistics, supervising health care workers, and providing necessary updates for effective vaccine administration.
The RMNCAH scorecard has become an invaluable tool in tracking the sub-county’s progress in immunisation. It offers a visual representation of performance through color-coded indicators (green, yellow, and red), which quickly convey areas of success and those requiring attention. The tool has facilitated targeted actions and informed decision-making at both the community and facility levels.
One significant achievement attributed to the use of the RMNCAH scorecard occurred during a community engagement session in Q4 of 2023). The sub-county’s immunisation status was displayed, prompting local Members of County Assembly (MCAs) to purchase reproductive health equipment for health facilities in two wards (smallest units of administration in the sub-county). These included autoclaves, oxygen anemometers, suction machines, examination lamps, penguin sucker, fetoscopes among others. Additionally, a private facility owner, struck by the scorecard’s status, offered to assist by providing outreach services and ensuring vaccines were available to improve coverage.
In the same period (Q4, 2023) Caroline noticed a significant drop in measles vaccination coverage (MR1 and MR2) and low uptake of the rotavirus vaccine, with coverage as low as 33%. A fact-finding mission revealed inadequate stocks of the rotavirus vaccine and the reluctance of mothers to return for the MR2 dose, which is administered nine months after the first dose. To address these issues, Caroline and her team implemented proper forecasting and ordering practices to ensure sufficient vaccine stocks and sensitised community health workers to refer children for MR vaccination during house visits. These efforts led to an increase in immunisation coverage whereby rotavirus 2 immunisation has improved from 33% to 75% in Q2 2024 and MR2 improved from 36% in Q4 2023 to 45% in Q2 2024. Efforts are ongoing to identify additional actions to further drive-up coverage.
Case study 2: RMNCAH Network: Leveraging the RMNCAH scorecard and Action Tracker to advocate for maternal and child health
Ouma Moses, representing the RMNCAH Network, an organisation established in 2018 through a coalition of grassroots Community-Based Organizations (CBOs), sheds light on their advocacy work. The network, consisting of nine CBOs, emerged in response to high maternal mortality rates, particularly from postpartum hemorrhage.
The RMNCAH Network has been instrumental in implementing social accountability mechanisms to ensure that advocacy efforts translate into tangible improvements in maternal and newborn care. A key initiative in this regard is the support for Maternal and Perinatal Death Surveillance and Response (MPDSR) review meetings. These meetings provide a platform for stakeholders at the county, sub-county, and facility levels to discuss maternal and perinatal deaths, analyse causes, and identify best practices for preventing future occurrences.
The RMNCAH Network operates within three sub-counties—Sirisia, Kanduyi, and Webuye West—where it has continuously supported MPDSR reviews. The insights gained from these meetings are critical in tracking maternal health performance and holding stakeholders accountable for their commitments to improve care.
To enhance the effectiveness of their advocacy, the RMNCAH Network adopted the MPDSR Action Tracker – a sub accountability scorecard inspired by the RMNCAH scorecard, allowing a deeper focus on maternal and perinatal mortality. This tool categorises actions identified during MPDSR reviews into levels that require support from specific entities, such as health facilities, sub-county departments, or the county assembly. The action tracker uses a color-coded system—green for completed actions, yellow for actions requiring further progress, and red for actions needing significant intervention.
The MPDSR sub accountability scorecard
The MPDSR Action Tracker has been pivotal in guiding the Network’s advocacy efforts. For instance, when a facility was identified as needing an ambulance—an issue beyond the facility’s budget—the Network used the tracker to target advocacy messages at the county assembly, engaging them through media and public participation to secure the necessary funding. This strategic approach ensures that the Network’s advocacy is focused, effective, and responsive to the most pressing needs identified in MPDSR reviews.
The RMNCAH Network’s advocacy efforts, through the implementation of the MPDSR Action Tracker, have had a profound impact on maternal health care in Bungoma County. By ensuring that commitments made by stakeholders are tracked and followed up, the Network has created a system of accountability that drives continuous improvement in care quality.