Lydia Anne

Impact of Implementing digital enabled interventions for Community Health Workers on Maternal, Newborn and Child Health in Kisumu County FIELD DATA- INTERVIEWS KII Transcription KII code: KII_LGStaff_peerCoachSupervoisor_104 Interviewer / Moderator: Lydia Bwana (marked as “M”) Respondent: 1 Respondent (Marked R) Date: 5thSeptember Name of Transcriber: Lydia Bwana Number of audio recordings: 1 Start of recording [Phone ringing] R:Hello M: Hi, good morning R:Good morning M:This is [name –Peer Coach Supervisor?] R:Yes M:Good morning [name], how are you? R:Good morning, I am well, how about you? M:I am well...is it okay we continue with our conversation? This is Lydia from Population Council R:Sure M:Okay, so as I did mention, we are doing a study together with LG and The Ministry of Health on the Implementation of the DESC, I am supposed to take you through a consent form which is supposed to be physical but because of everything that is going on in the country right now, I will just do it virtually. Now, you are being interviewed because we would like to know your role in the rolling out of the DESC project in the County and maybe your views on the intervention of the project R:Okay M:Yes, there are no wrong or right answers we just want to hear your honest opinion about the intervention and everything we are going to be talking about is going to be confidential, okay? R:Yes M:Yes, so no personal details will be used, in fact it is already wrong that I did mention your name but we will scrub that out when we are doing our transcriptions. So everything will be anonymous, we will just use a code to name your transcripts, is that okay? R:Okay, that's well in M:Right, so we are going to take around 40 to 60 minutes give or take, depending on how you answer the questions and there are no risks, the only risk is that bit of your time that I might be taking, there are no direct benefits that are going to come to you as a person, but we hope you will feel good knowing that you participated in something that is helping improve the health system right from the community level to the facility level or to the people at the top-the stakeholders. So, I will just need a verbal consent; did you understand everything and are you okay participating in this survey? R:Sure, we can proceed M:All right, great, thank you very much. Now to my first topic, we are going to talk about Perception of Digital Health Policies and Framework; kindly tell me about the national community health digitization strategy R:What is the question...what should I tell you about? M:What was the motivation towards the development of the eCHIS policy? R:So, motivation towards the development of policy for digitization...I think looking at the health strategy, in community health strategy we have the different elements that needs to be done and it is out of number four or five, there is an element to it that speaks to having a digitized system as a way of strengthening the community health system. So, I think in that light, this is what gave birth to the strategy that was-the national digitization strategy... M:You can use any language that you are comfortable with; I know sometimes they go back and forth R:No, they are just not on my fingertips but I have those documents somewhere, so I might misquote them a little bit M:Are you nearby somewhere maybe you can take a look at them? R:I have to look for them; maybe a minute or two, maybe we can move to another question M:Maybe you can just look for them and have them handy, I don’t mind waiting R:You don’t mind waiting...? M:I don’t mind, I had already set aside my time for this R:Okay whatever I was looking for is just here [Pause]...we can move on now M:Okay R:So when we are looking at the strategic directions for the Community Health strategy 2020/2025, we have different...they are around seven, so Strategy Section One is about strengthening, management and coordination of community health government structures, Strategy number two-across all levels government and across partners; number two is to build a motivated skilled, equitably [Unintelligible 05:34] community health work force, sustainable financing for community health [Inaudible 05:42] direction is number three, so number four is strengthening the delivery of integrated and comprehensive and high quality community health services, number five is increased availability, quality, demand and utilization of data, so number six, is ensuring availability and rational distribution of high quality commodity and supplies and number seven is creating a platform for strategic partnership So, looking at all those strategic directions that we have within the community health strategy decision 2020/2025, we see that in direction number five where we want to have an increased availability, quality, demand and utilization of data, I think this is also what informed the National Community Health Digitization Strategy. So, there was done a landscape and partners I know were called and from that then, there was a need to embrace this element so that it supports us achieve that strategy. So, with that came community electronic health system information where we are just using...from the landscape assessment report, we are able to inform the National Community Health Digitization Strategies on areas that we need to look into. So, attain that 8it means that maybe for the community work force to have them digitized, we need to have success and the visibility of the data that they are collecting. I don’t know if that answers your question but I believe it is a step towards M:It does...so I just remembered that I forgot to mention that we are recording this interview because I cannot write everything that we are talking about and everything is important R:Okay M:So how was the development of the strategies, aligned to other government strategies and policies, in health and digitization in general? R:So which strategies in particular, ECHIS or the digitization strategy? M:You have talked about seven of them, maybe you can pick some that you feel are aligned to other government strategies and policies in health and digitization in general; not necessarily all of them R:Actually, it is all of them because these are strategic directions towards implementation for Community Health Strategy. So, when we talk about digitization, I picked number five because that's what speaks directly into digitization but the rest are things like supply chain, work force issues around it M:How about the primary health care strategy, how is it aligned to other government strategies and policies in health? R:They provide guidelines for the design and implementation of programs that are targeting the strengthening the primary health care system in Kenya M:And the government digitization policy R:So, for the government digitization policy, that is the National Community Health Digitization Strategy...so what do you want to know about it? M:How are they aligned to other government strategies, like...so you did mention different strategies, and we know before LG came into the picture the government already had its strategies in dealing with health and issues like that, right? R;Yes M:So how are these new ones supporting each other with the older strategies? Do you get it now? R:Okay...so these digitization strategies in relation to other guidelines and policies? M:Yes R:I think they are different...towards health or towards digitization, which way should I face? Because the question is too ambiguous, but maybe I will give it a shot and then you tell me if I am taking you to where you want to see or to go... M:This is qualitative; so, with qualitative it is free range-you can take it towards the health side of it or towards digitization or combine bot. How is digitization used to provide health services or to better them or to improve them? R:Well, if we look at it holistically and I will start maybe with the constitution. Within the constitution we have different clauses that speak to providing...people having the right to the highest sustainable standards of health, people having the right to access of information, individuals having the right to information relating to their family and private affairs And when you look at the community health system, that is the digitization bit, it has effort to support the attainment of highest standard of health because the digitization strategy will provide privacy and it also provides the access to the information that is required, that we are talking about in the constitution that people need to have So, you look at different health information system policy where it guides on priority areas for information system should focus on, it has [Inaudible 12:00] the roles and responsibilities of different stakeholders and give directions on resource mobilization. So, looking at community health information system digitization, it also helps in supporting that...the re-integration of various health systems by linking health information, community management and community information systems Again, it also a tool for community units which is developed and put in place to facilitate partnership within the community units, so an example is even the data that we are generating here in Kisumu, we aren’t the only consumers in as much as Living Goods is the implementing partner. So, partners even across board, even outside Living Goods are consuming this type of data we are having, because of how we also work closely with the same HMTs that we are working with. So, looking at the community health policy, it envisions a community that will collect data based on activities of CHVs as well as generate information on community development issues, socio-economic and demographic [Inaudible 13:23] of households Looking at the community health system, we are able to collect that data using the application and this may also be deployed to ensure that community health data collection and reporting is strengthened. So those are things that I could think of top of my head, I had already mentioned for community health strategy and the strategic direction-number five, where community information system, the digitization that now we have, is also supporting to help us achieve that. I would say those are from the top of my head but if I would take more time maybe, I think there are many policies that are intertwined with community health information system M:It is okay. Now, who are the main stakeholders involved in the development of the strategy? R:Stakeholders involved in the development of this strategy-the National Community Health Digitization M:Yes R:I think there were different partners who came together to do the landscape assessment and all these partners, most of them are from Ministry of Health; other than Ministry of Health, partners within the health space as well as the ICT department M:So, you mentioned that there was MOH, ICT department and then other partners from the health department R:Yes M:Would you kindly tell me the roles of MOH in developing this strategy R:So, the specific role of MOH in the development of the strategy? M:Yes R:So, ...I am too sure.... M:There are no right or wrong answers R:I think because it is a national thing, different partners always have different interests though the scope of health is wide. So, I would say the role of MOH was one, to create that central hub, to pull all these resources together so that they can sit down together and have no duplication of roles where we have a shared understanding on what the health information systems should do and how it would benefit all other partners, just to remove the duplication that would come with it Then another thing, for MOH I would think is by pulling to reduce the duplication of roles as well as to bring resources together because this is an activity that needs some funding and cost. And also, maybe to give a strategic direction on how they think this would be of benefit to them M:How about the ICT department, what were some of their roles in the development of this Community Health digitization strategy? R:So, the use of ICT I think for community service delivery and data management is not so limited. One, if you are talking about data-the quality of the data that you are collecting, how do we secure our data so that it is not misused, what are the tools we would want to use that are efficient and we can afford...yes, data protection and management issues around it M:Okay, how about other partners in the health department? R:So, for other partners I would say that they were also looking for themselves what the return on the investment is, if they would support this course. Although different partners have different needs, there are those partners who are only interested in only one area within the health system; health is very diverse, so I would say that, that would be tailored towards the objective an organization would want to achieve. I would give an example for Living Goods, for us maybe because we had wanted to scale up rapidly to ensure that every mother and child wherever they are, they are able to get the care they need to survive and thrive. So doing it as an organization as Living Goods would not be a [Inaudible 18:55] [Call disconnected 18:57] R:Hello, is it my network or yours...? M:I don’t know but it just went mute [Recorder had malfunctioned and parts of the audio got left out, though the question was asked and response repeated at the end of the interview] [Call Reconnected 23:47] R:...who are accountable because they know that there is that visibility. Another thing I just wanted to add was the quality of the service delivered, at least people will standardise because the platform has a standardised messaging, so whether you are a CHV who went up to class eight level or form four level, there is no that struggle that to have to remember things because within the work flow you have standardised messages that we have and just remind the CHVs what to do. So that also improves the quality of health care given at the household level M:Okay, what are some of the opportunities that have risen up, due to the rolling out of the ECHIS strategy? R:Opportunities that have risen? M:Yes, like are other counties...because we do know that DESC is not being implemented in all Counties in Kenya, right? R:Yes M:So, you have just specific counties; are there any other counties which are maybe getting interested and wanting to you know, get DESC within their areas R:As I had said, even today in our Monday morning brief...we have our Monday morning meetings every week; we have just gotten highlights and updates that the focal persons for the 47 counties were converged for a meeting, they were reviewing the level of maturity within their counties, where they are at with regards to being able to adopt DESC. I can say there is a lot of interest only that this is an area that hasn’t been...most government was not keen on because everyone is talking about UHC and accelerating coverage, everyone understands and CHV roles has started being appreciated better. I would say that yes, we have had interests from different governments who would also want to work on DESC, even the 47 counties-both implementing and those who want to implement have decided that they would go and start to access their capacity as early as now, so that they can start ironing out or strengthening areas that needs to be strengthened so that they might be able to advocate for and have them to adopt DESC So, it is a good thing because of the return of the investment, I believe that this is an area that most county governments would also want to adopt M:Okay, what are some of the challenges that you have faced in the rolling out of the ECHIS strategy in Kenya? R:So, I would give an example of where we are-in Kisumu, and what I have seen not working well, especially we have been having downtimes [Inaudible 27:20] downtimes and application downtimes. And reason being, when we were having this partnership with the government, we were looking at what is the most affordable within the market, and what is that which government can sustain. So, when we chose an open source-where we are using superset for our dashboards, you get that they have quite some limitations when the numbers grow bigger, the...I am not a tech person...I don’t know how I can call it. When the users grow bigger...you see for the open source you don’t pay for the services-you can generate, you can have your dashboards in them; you don’t pay to have them ‘housed’; let me call it like that. So, it is not very efficient for a very big number of users. So, it is an area that any government that would want to adopt...my recommendation would be they think through and maybe they have a budget for those [Inaudible 28:33], even if they are paying for having to use those services that is being offered so that it gives them quality services than opting for free services that comes with a lot of downtimes and challenges around it Another challenge was to change behaviour. With the adoption of the ECHIS it means that life would not be as normal, not business as usual. Looking at how government staffs are used to doing their things in a plateau for a very long time where they aren’t accountable, they divide their work hours to do personal stuff...but now this is something that would keep you on toes because everybody has visibility of it and on a real time basis. So just rallying up these people and having all these thoughts align [Inaudible 29:37] to accepting and embracing the digital component is also time consuming. It is a challenge but let me just say it is time consuming because it is something gradual because of the behaviour change M:Definitely...any other challenge R:Another thing I think is that we don’t select CHVs; we work with the existing Community Health Volunteers but even before community health strategy we had volunteers in the past, only that community health strategy has helped amplify what the CHVs have been doing and giving them recognition. So, we have CHVs from way back, even when their activity was not being recognized. Some are old, some aren’t literate, but this is a tool that now you are introducing something that would want a person to have some basic level of education So, it would mean that governments would want to do some re-selection again for their CHVs so that they wean out the older ones who cannot catch up with technology, those who are very illiterate and on-board new ones. So that was a miss for Kisumu when we came. I think the understanding was that it is something easy and anybody can do it. So, all the CHVs were given to us as they were...so you find that during training you have spent a lot, you have invested in a CHV but the CHV is illiterate and cannot catch up with the technology which makes people drop along the way after they have been trained leaving pockets of villages that aren’t covered. So that's also an area that maybe people would want to look into M:All right....is there any other challenge? R:Ratio-I think human resource within the county government is still not having the ideal ratios. You would get like...I would give an example of a quick one, for Kisumu East we have 476 CHVs with 470 already trained with only 7remaining, and there was a time that I had one Community Health Assistant –CHA; having 40 CHVs. So those numbers are big; they are not realistic and even within, you get that of the 25 CHAs against the big number of CHVs are around eight are volunteers, these are people who would leave anytime. So, if they would want to have this work and well, maybe they would need to consider also having a complete work force that also give us the correct ratio of staff-CHA to CHV Other than that, also I would say we need also to [33:04 Inaudible] because these are digital tools which have a shelf life. Maybe plan around what happens when the shelf life of a phone expires? What happens when a phone is lost? With whom does the cost lie? So, costing around these things that will be reused like the phones would have stayed for long and they start slowing down, batteries are drained; so how do you replace that phone for the CHVs? M:Okay, so right now, amongst the stakeholders, who provides the equipment-the phones and all that? R:So, we have a co-financing agreement with the government, so we heavily invest during the initial stages, maybe LG 70% and the government 30%. But as time goes by, we reduce our investment as the government increases theirs. A time will come when maybe we will be pumping in maybe 10%and the government doing 90%. So initially LG as an implementing partner they cater for the phone cost-they buy for the CHVs the phones and the training aids like the flip books, work books that they will require as well as human resource during training, but thereafter, even the phone contract that the CHV has signed it is like you have been issued with a government gun, if you stop working for the government, you take back the gun, if you lose it, you look for a way to replace...but this is now not a gun, if you lose it, you replace it, so the cost lies with the CHV. And this has slowed things down a bit because you find we have phones that were lost sometimes last year-early April, that are not yet replaced to date. It means that that CHV’s village we don’t have visibility of their data and we also go back to checking on the manual reporting tools. So, it is costly to CHV, some it is not quite affordable for them, some have been paying it with their stipend money when it comes, but it is an area that needs quiet a lot of thought to go in M:All right, now, what has been the experience so far in terms of implementation process of the ECHIS strategy? R:I would say that what has made it work and work so well, is political good will. I think if...it is the blessing from the fathers of the county, everything would run. So, the political good will, they really wanted it, so it them who sought after us. I think this came when we were doing...then I was still a trainer not a supervisor here in Kisumu; we were training in Isiolo, we would work there; Governor Nyong’o came during CHV graduations and he was interested and that's how he brought us to Kisumu. So, when people are aligned even from the top and things are well cascaded and communicated up to the bottom, the last bit, I think it makes things easy M:All right and how effective has it been so far? R:I would say you should come to Kisumu and attend one of our data reviews and see what we are doing M:I am in Kisumu R:You are in Kisumu? M:Yes R:No, you are not in the heart of ECHIS in Kisumu M:Just not where the real action happens, but I am in Kisumu. Ideally, I was supposed to meet you physically R:Now that's what I am telling you; that is the Kisumu in this regard, where the things are happening M:Yes of course R:I would I am very proud to see how there is ownership from the MOH team. So as a supervisor I would say my work is very easy right now because they rung the show and I am confident if I were to leave Living Goods today for my Sub-County, there will be work on going. So, they have embraced it, they took it and they run with it. So, it is just about cultivating relations with the Health Management Team at the Sub-County level-If it is within the county level do it with your county level; in whatever space you are in, just connections and have a shared understanding that makes work easy. So, they run the show, they are very capable of doing it, in fact we received guests....and I am nowhere close to that course, it is them who go and showcase what they are doing, my work is just to lead from the back M:Great...now, what are some of the opportunities that are there, to improve the rolling out of this strategy? R:I would say what we should think through even as Living Goods, we have been transferring...I always tell people we are working ourselves to redundancy because mine is to transfer knowledge and make sure these people are able to run with it. When they are good, then it means that I am not needed here. So, it is so well within this operational work that we are doing but then on the front of monitoring and evaluation, on the front of the technical digital health team-people who troubleshoot tech issues, work flow issues; it hasn’t come out so strong. So we don’t have...I know that from my end there is a person if I leave, they can look at the data, they can analyse, do performance management, do back checks...I am very confident that there is someone from the county right now if LG was to remove its support, there will be people who will be able to trouble shoot all these tech issues that we are having, there will be a strong M&E team to do QC and all those checks. So, I think we have an opportunity to make sure that we have those systems up and running but as is now, we are still low on it M:Okay. So how has the ECHIS policy been incorporated in LG’s roll out of DESC? R:So, what the policy aims at is just visibility or access of data and utilization of data and I would say that's exactly what we are doing. So, talk about community health indicators that the CHVs are collecting nationwide using their manual tools, plus the work flows that we are having, this is aligned to all the indicators that are within the paper based. So, you would see that a CHV doesn’t miss out on any indicator because they are using the digital platform, so it is a replica of what they are collecting, so it is 100% in sync. Areas that would even make it a plus, areas that we are still working on is to ensure that now we can transmit this data to KHIS digitally. We tried that and we noticed some misses, now it is back again to our GAC, engineers are trying to fix that, but it was even exciting to the focal knowing that she has 44 CUs, she wouldn’t have to be doing those maths and keying information for all the 44CUs manually, hers would just be to look at the triggers sent to her for verification, hers would just be to approve and the data is automatically transmitted to KHIS M:What elements of the ECHIS did you tweak for contextualization? R:What context did we tweak...? M:Yes, something that was on the ECHIS but you changed it a little bit and used it on the DESC R:Even before ECHIS came to Kisumu with...we call it mainstream instance; so mainstream instance was built but wasn’t aligning to those indicators that I have spoken to, so I would say that the greatest thing that we have already done, the government was to align the instance now to be a replica of what the MOH requires. So, I would say for that we are fully aligned Other bits of the DESC element like supervision, we have worked with the supervisors to understand their needs. We have collected requirements on those areas. Like the supervisor app that we are having-for CHA to CHV, but remember CHAs also have their supervisors who are the focal persons. So, the Focal persons don’t have a tool to appraise or to give supportive supervision to their CHAs. So, I think we collected requirements from those, we had a meeting with the Focal persons, we understood that yes, we have a supervisor up but it is limiting, it doesn’t serve them and we are very much waiting for the white smoke from the GAC team to tell us now, this is done So, we are happy to know that even the focal persons will have a supervisory app that will enable them also be able to offer supervision to their subjects M:Yes...how have you been engaged in the development of DESC as a Peer Coach Supervisor? R:Collecting user requirement because we are the first people who interact with the users, so we collect user requirements, if we have an issue we raise it, when these works are done, prototyped and ready for deployment we are the first people to do UATs before this is released M:Any other way? R:So, with the DESC I will limit it to the ‘D-Digitization’; on equipment, we also equip the CHVs with knowledge skills and attitudes, we have our weekly CU meetings, we do CHV refresher trainings, for the CHVs we trouble shoot any issues that would impede their working in those meetings. On supervisions we shadow the CHAs; we coach and help them to see how they are doing their supervision trying to move them away from the traditional way of supervising to making it supportive and... Compensation not so much from out end as peer coaches and peer coach supervisors but I believe there is a team that works close on that M:Right; how do you see DESC being integrated in the national digitization strategy? R:It is already there; it is not about being integrated, already the national digitization strategy speaks around the DESC component because they talk about digitization, use of data...yes, so this is not...we cannot look at it as a half empty cup but I would rather say that it is half full, because these are things that are already within it, maybe it is just how it is implemented that might vary according to the needs of the different counties M:Okay...what gaps is the DESC addressing in the current Community Health System? R:Availability of data, up to date data, long gaps-you know like there are regions the under-reporting thing, people would not collect reports on time, but here now we have it real time M:Right, any other thing? R:Another gap was on quality of data-you are just given aggregate at the [Inaudible 48:29]. A CHV can generate data under a tree at the end of the month and submit when they are using the paper based. But this one now, at least the quality...we can count on the quality because they know one, there is GPS coordinates that tell us where you have done your entries, two you are interacting with real time people where we can see this household, this number of people, this is the contact...it is easy to do quality checks unlike how it used to be M:So, there is accountability of some sort R:Yes, and the data is more credible M:Right, any other gap that DESC is addressing... R:What have I mentioned? M:Availability of data, then there is the quality of data and then there is also...it is something that you are sure of, it is not made up... R:Accountability also of our staff. So right now, you know if your staff is going to work or not because they also have a supervisor tool where they key in who they have supervised and when unlike in the past where people would do their things and only go to the field during report collection. And again, now you know, because we are doing quality checks, if we see a CHV is not improving and as a supervisor you tell us every other now and then that you are supporting them, we would want to know what you are doing with that CHV. It has made MOH staff to be at least accountable in their actions and in their work M:How about in terms of timeliness of data; data being presented on time? R:It is real time, it is just syncing and everybody is able to visualize it unlike in the past when it was during collection of data is when it would rain and the CHA would tell you there is no access, the roads are impassable and stuff like that M:Okay so you had challenges R:Yes M:Right, so we are going to my second topic, we are almost halfway through I think, it is talking about current data collection, data utilization landscape; how is Community Health Data currently being collected in Kisumu County, and maybe you can talk about the Sub-County where you are based? How does data flow from the community to the decision makers? R:So, Kisumu we haven’t migrated fully to digital reporting, but the system still remains the same nothing has changed other than it has been improved and now on a digitized platform. So, as was, the reporting still remains the same where the CHVs do their service delivery-collect their data; so, the difference is that they used to collect that data, aggregate it towards the end of the month on their MOH 514, so the CHVs would then give it to their CHAs who is their supervisor, if the supervisor has ten CHVs she aggregates all of them from a community unit. So, from the CHA it used to go to the focal person and in Kisumu it goes to the HRIO [Sp] who keys in the data for community...in other places it is the HRIO [Sp]; now it is from the focal to the KHIS when the focal has reviewed it. So, it still pretty much the same only that now it is on a digital platform where CHVs collect using their phones on a daily and sync daily, though towards the end of the month, I think by the 5th, the CHA receives an MOH 515 trigger, what it does it just aggregates from the back end all the CHVs within that CU. So, she just gets the aggregates from her CU. If you are having two CUs, you will get two triggers for the two CUs. The CHA goes through the indicators just to confirm, if she sees a mistake somewhere she is able to edit and then they submit it. Then the focal person receives the same, after the CHA, for the focal person hers is just to review and press approve and when she presses approve, it goes direct to KHIS and that is something that I had early mentioned that we are waiting for the white smoke, at least there were misses that we noticed that are being rectified M:Thank you for that. What are some of the challenges that impact data flow? R:Not so much within Kisumu east but I know there are network issues. It would mean that a CHV has to periodically go to some place where there is a bit of stable network for them to sync their data Another thing is these downtimes. We are having the applications white listed, but I don’t know what happens from the white listing source. So white listing means that the application...getting into an agreement with a network provider like us we have an agreement with Safaricom- any Safaricom line can access the application without me having to have bundles, as long as the data is on, I am using a Safaricom line and it is this application that I am going to access, even when that line has no airtime, I can still access it. So, since we are having that white listing down time, so we don’t buy bundles for CHVs, it is the app that is whit listed and we provide the Safaricom lines So sometimes I don’t know what happens maybe the tech resource can explain it better, but we just call it white listing down time. So, when it happens it means that a CHV would not be able to sync. So, it can prevent that data flow as expected M:Yeah...you won’t get it as timely as you should R:Yes M:Right...any other challenge or barrier that impact data flow from the community to the decision makers? R:Not really major challenges I would say so, you know the tech issues sometimes we have a down time not only for white listing, maybe the application itself maybe like the super set we are using the open source, sometimes there is just downtime and I can’t explain what happens. And it mostly happens around towards the end of the month and I believe sometimes most CHVs don’t sync their data as often as they should, especially those one who are impacted with regions that have poor connectivity, but towards the end of the month, they would want to move to make sure that they have synced all their data. So I think documents become too many and it slows down the servers M:Right, how is the data being used at different levels of the health system? Let’s say how is it being used at the community level, at the health facility at the district level, the county and now we have the national...? R:Okay, I would want you to leave it at the Sub-County level... M:It is okay, that's the furthest you can go, yes? R:No, it is not the furthest because the algorithm is the same, if you get it at the Sub-County, it still relates when it gets to the top. So, I would give an example of just the ending month-August; before the month ended, I was being pressurised to give back-end data so that we can see which particular CHVs reported maternal deaths, and this was an ask by the CEC Health Kisumu. So, like in my Sub-County we had five maternal deaths M:What is CEC in full please? R:What is it in full...just note it down I will recall and tell you M:It is okay R:CEC Health... M:It is okay; we can continue R:Chief Health Officer-CHO, so it is usually the CEC and the CHO. Now he had noticed that we had...it is County Executive Committee of Health –CEC Health; yes, that's what I was forgetting. He had noticed that Kisumu east had recorded five maternal deaths at the dashboard. That is a lot, for you to have five maternal deaths there has to be something wrong. One we need to understand, where are these deaths happening-is it at the community or at the facility? But from the dashboard we are just able to visualize that there are these particular number of deaths in this region. So, for us to narrow down, we request for back-end data, so that we can be able to narrow down to the individual CHVs who recorded these deaths M:Somehow like a history of why? R:Yes, so that we go and visit those families-you know, which villages these deaths are happening from and why. So, this is just to inform that this data is being [Inaudible 59:36] and being utilized. If the CEC is the senior most in the department of health at the County level being able to see what is happening at the Sub-County, has interest to know at the lowest level which households, which villages... So, yes, we use this data, we review the data...we collect the data on a daily basis it is being synced but we review the data on a monthly basis. So, there are key statuses that we look at. Within the County Health Management team, we are led by the MOH, then we have the different Program Officers...health is diverse so we have a Program Health Officer like The Sub-County Community Health Strategy Focal Person, you will find a Coordinator for TB, you will find a Coordinator for Rehabilitation, you will find a Coordinator for the different segments within health So, during our data review we talk about these indicators, we see out [?], we flag areas that need interventions and it informs even the activities of the preceding month. So, like now we are in September, before the 12th we need to have reviewed August data. During the review is when it will inform the health coordinators what we are going to do. So, we realize there are a lot of diarrheal cases in a region and we need a dialogue day and action days that is what we do. So, it helps us in planning interventions and areas to focus on Same to the facility-at the facility level we also...during data reviews we have the in-charges. We look at even the trend consumption of commodities; it even informs the Sub-County Pharmacists and the link facilities in-charges, on the quantities of commodities that need to go to the community. It informs them on how many women were referred, how many reached the facilities and where did we lose. If we say like ten women were referred and the link facility only got three women, where did the seven go? M:All right R:Yes, so it informs a lot of things within the health space both at the community and at the facility levels M:How about at the district level, how is the data used? R:Still same thing because you know at the national level, say broadly they use this data for policy making. But health was devolved, so implementation is at the County level. So, if the policies are made at the National level, at the County level, they tailor it to fit the needs of the particular County. Different Counties have different disease burdens and different needs. So, from the National framework is where they also make their own that supports their County. I would give an example at the National level, our Community Health Strategy it is allowed for pneumonia to be treated by the Community Health Volunteers...Uncomplicated Pneumonia cases. So, the Sub-County has already adopted that, they have grained it to their county policy. But in Kisumu we still struggling with it because we haven’t embraced that bit yet, we have still not allowed CHVs to treat pneumonia at the community So, I would say that that's how this data is used, so I would say that it was easier probably for people in Kisumu to allow for the malaria treatment because it is malaria endemic. And how do we know that it is malaria endemic? Because of the very many malaria cases that we are recording from the community to the facilities So, at the National level it is the policies and at the County level implementation; in fact, both policy and implementation. So that is how the data informs M:All right...and how is the information communicated to the various levels of the health system? Especially the information that is used for decision making and action-how is it communicated to the various levels? R:Okay I know we have different technical working groups even within the government; I will talk about them because they are the main stakeholders. So, within there are different communication working groups, we have representation from the different Sub-Counties. These representations are drawn from the Heal Management Team. So, they discuss there... within the Health Management Team at the Sub-County they have their Monday morning briefs, this cut across. So, at their Monday morning briefs that is where again it is discussed and it is cascaded. From there it is the Program officer who is affected, works closely with the Sub-County Community Health Strategy Focal Person because she is the link, to plan on how to cascade it further to the CHAs, from the CHAs they cascade it to the CHVs, sometimes through the CHVs leads meetings or directly to the CHVs, if it is something that needs mobilization then the CHVs pick it from there, they mobilize, a date is set and the Program Officers go and support M:Great...how is the Community Health data that is collected used for decision making? I feel like you have already touched on this but maybe you would like to add something R:So you still want to know how it is used for decision making... M:Yes, I feel that you have touched on it R:I have really tried explaining that so well and put so much effort M:All right, let me just probe a little more using a bit of prompts here and there, maybe it will remind you of something that you didn’t talk about R:Okay M:How does the County use Community Health data for policy making-that one you have talked about; how is the County using Community Health data to identify gaps, at the community level that needs action? R:I mentioned that I think M:You mentioned that...how about in addressing health issue that have been identified? That one you talked about because you talked about deaths and... R:Dialogue days... M:Right; so, this one is going to talk about MNCH services; how does the County use the Community Health data to improve MNCH services specifically? R:Let me add R at the beginning –Reproductive health M:Okay R:Ask me that question again M:How does the County use the Community Health data to improve MNCH services specifically? R:Maternal, New-born and Child Health services? M:Yes R:The classical example that I have just given.... M:Yes, of the diarrhoea and the maternal deaths... R:Especially the maternal deaths one which falls under MNCH; s it is very alarming and I would also tell you like now we are keen on it because in Kisumu we have identified that most of the mothers-pregnant women; do go to the facilities during screening even before delivery and are found to be having preeclampsia, they have high blood pressure. And we were even asking ourselves what should be done because as it is right now, we are not collecting that data from the community level. Reason is because it is not a data point within the work flow, again the CHVs during the initial kitting they were given manual BP machines which is very hard to operate so we then withdrew it from the CHVs kit. So that if there to be screening for blood pressure they would need the digitised machines So, we collect data on maternal deaths; these are being followed up closely; and we also have noticed that regions like Nyando...we have spoken about it during our data reviews; when we get that CHVs are recording high number of home deliveries, we would want to know where the gap is. At times it is the distance, we have also seen facilities being opened up like in my Sub-County, the other month we upgraded some facilities from Dispensaries to Health Centres and we have opened up Dispensaries closer to the CHVs where we had not attained the recommended WHO distance So, we have Obino that has been opened up, we have Madi [Sp] that have been opened up, we have Chiga that's now a health centre-it has a maternity wing you know...so this data also informs us to talk about...when you talk about children, we are looking at children who are under immunized-which areas are they coming from? So to improve this there are times we had to do campaigns for immunizations for children, we had to do dialogue days with the communities where we felt that in these regions there are many babies who are not being immunized Just the other day we were talking with the facility in-charge here at Simba Upepo, looking at the linkages, the numbers that are coming in and comparing it to the data that we are generating, I think we agreed to look for a way that we are now having targeted out reaches, not just having a crowd and calling it an outreach. Now since we know households where these under vaccinated children are coming from, why don’t we then have that cold chain, we have the cold box, we have a nurse and a CHV, that we go directly to these houses so that these children can get immunized So I would say that we consume that data a lot...not as much as we would want to because again it is huge; it is a lot of data, but I’d attest that it is contributing to strengthening of service delivery even at the health facilities. We get facilities were you refer somebody and people don’t go there. You get referrals for pregnant women are not going to that place. We sit down with MOH, we go to the CHVs during our meetings and they open up-plus in these facilities the ‘sisters’; they are called sisters; they are not so kind to women, their attitudes are wanting. We have even seen people who have been reshuffled... M:Oh really? R:Yes, there are those who have stayed in a facility for so long until they felt like it was their home and they were running it however they wanted... M:So, they are just now doing things for the sake of it... R:They are just doing it for the sake and they don’t care, nobody used to follow up on them and they would [Inaudible 1:12:47] away women who want to go and deliver there, women who have been referred are not comfortable they don’t want to go there because of how they are being treated, just the service provider attitude. So, it has really helped even improve service delivery. It might not look like very many huge changes that have happened; it is small steps towards the right direction M:Do you feel that the fact that you know, everything is digitized now is kind of bringing in the aspect of accountability and thus improving service delivery in these facilities? R:That I would say yes and no, because it is not a closed loops yet. The digitization ends at the CHV level and the supervisor. We are hoping for a time where even the facilities will have a digital health platform, so that when we talk about these referrals, we stop sending people with just papers without knowing where they are going. Even at the facility level, when we refer a person, we have a trigger on that desk-on that laptop, the digital health platform at the facility where the in-charge can also see the referrals and we can track them digitally and we can see them referring back the clients to the CHVs after offering services So, there is a gap there where the facility in-charges unless we pull up and generate that data for them and maybe they join in on our data reviews that we are doing monthly, at the facilities they are still totally manual, so we don’t have the real time visibility of what is happening at the community and the compare it to what they are offering and how the linkages are being strengthened M:Right, so you have jumped into my next question which was going to talk about the loops that are there in completion of a referral. Maybe from the community to the facility...can you mention any other apart from the fact that the in-charge doesn’t get to see everything in time and maybe getting back to the CHVs from the facility. What are some other loops that are there when it comes to completion of a referral process? R:I think that's the greatest, we have tried having a desk at the facility and having a CHV there... M:A CHV desk... R:Yes, a CHV desk and a file where they are collecting these referrals every other day. But again don’t know because not all referrals are coming to that facility, we are still losing out on where others went, we still don’t have that visibility-you wouldn’t know if they went for the referral or not, we have to go back and ask again they went for the referral, where did they go? So just the same way as we have CEC sitting and seeing Kisumu East, Kisumu West...All these Sub-Counties, I think we also need to have a visibility that if maybe we have a unique identifier for each and every referral triggered, at least doesn’t come to a facility in Kisumu East from their link facility and chosen to go to Central, we are able to track and know that these people yes, they were referred and this is where they went M:Great...now, how is the County using Community Health data to improve logistics of commodities that are needed to improve MNCH services at the community specifically? R:How they are using the data to improve logistics? M:Yes, for example knowing how much medication was used, supply and such like things. How are they using this data to improve MNCH services? R:That sits very close to the Sub-County Pharmacist and for other communities and none [1:17:24 Inaudible] season sub-county pharmacist, we also have the lab coordinator because he gives us the RDTs, we also have the malaria coordinator who does the quality checks on how these commodities were used. So, we used the data a lot especially in forecasting and [Inaudible 1:17:47] commodities. So over time we have been able to understand, to see the trends in consumption, so we know which CUs where to take more and which areas are not consuming more When we talk about moving of...if the medication has been brought, the consumption will not be the same for all the different CUs. We are able to use the data to see where consumption is low and where it is needed and that would inform the sub-county pharmacist to call, which link facility. So, we've had situations where even when we don’t have more commodities in the main warehouse but know that this link facility has more commodities for the CUs, we send for some for the area that have exhausted theirs, so commodities get transferred from one link facility to the other where there is need M:Right, how well is DESC informing decision making in health? How well is DESC supporting health service delivery activities at the community level? That is the huge question that you can talk about; it will open up so many things R:It is the reporting tool that they are using, all indicators are aligned there, they don’t have to carry big books on their shoulders and walk with them. Now it is just a phone in their hands and maybe a flip book. So, I would say it is strengthening what was already there, we didn’t invent the tool, we only replicated it in a faster and efficient platform which is the phone. So, I would say it has even strengthened service delivery because one, there is the real time data, standardised-all CHVs speak the same language, three it is targeted-it has a task bar where it informs the CHV who to visit and why, four a CHV doesn’t have to remember and do all the traditional calculations while giving doses, at least it is in the phone, the work flow is very nice, it even gives the diagnosis and treatment. It has made easy the work of the CHVs and the process of collecting this data and how to analyse this data because you don’t have to have a hundred papers and start putting them together. It exports something on an excel and use all those formulas that are there to generate data very quickly M:So, you have basically talked about how the CHVs are using the DESC platform; how is the platform being used by the supervisors? R:So, the supervisors have two-one a supervisor app which has a checklist of what the supervisor needs to do when supporting their CHVs-the stock levels, the preparation levels and what they are having. It looks into the different areas that are of supervision because when you do the door-to-door visits, there are different thematic areas. Today we might find an under five who is a well child, not sick, and we still assess them-their immunization status, their nutritional status...so it has broken down these areas, is it immunization, is it on pregnancy, what did you do? Whom did you observe? And then from there again it generates a conversation, what were the areas that needed support? Did the CHV do well? And it is also a reminder to the supervisor on areas that they need to talk about with the CHV. It is about that; it records So even if a supervisor has to go, if another supervisor comes, it is easy for them to pull a report to go through, have a desktop analysis of what was being keyed in the comments about these CHVs? What are the areas that this CHV has been struggling with? When he seeks it, it is just very easy for them because they have that historical data about the CHV M:All right, now what is motivating the County to roll our DESC? I know you did talk about Governor Nyong'o attending your training and then... R:Yes M:But I know you have titbits like why did they want DESC to be rolled out in this County? R:I think the motivation is the ability to accelerate UHC-Universal Health Care. So, health is an area that has been close to our Governor I would say so and in Kisumu we have had partners over time, we have had challenges, this is a lake region...you understand there was a time HIV prevalence was very high in Kisumu, people’s immunity was very low and again you understand that health is wealth. If you the people are not healthy then there is nothing they can generate So, I think what motivates them is their walk, they understand the importance of good health, maybe they have been affected directly or indirectly by it. And also, it was a big push...it was one of the four agendas for the government that we want to accelerate universal health care reaching the last person. And I would say that this even challenged them to start having those conversations, having included CHVs and having built, just having them engrained in law. So, I would say their motivation is return on investment, truth be told it is easier to work with the CHVs-one they are volunteers so professionalizing them and training and equipping them so that they can help decongest our hospitals, they may be able to have health education especially on promotive [?] and preventive health is cheaper than curative. We can never have enough nurses. So, it is the return on the investment, leveraging on the CHVs for UHC, I think that's their greatest motivation M:Okay, now you did talk about the strengths of the DESC, now what are the weaknesses, if any? R:Just the down times that I spoke about M:The network R:The network, white listing, CHVs were illiterate who cannot pick it, behaviour of the people who should embrace it M:Okay. What challenges do you foresee with the integration of DESC at the County level? Maybe even when LG leaves, what challenges do you think they will encounter? R:The sustainability plan. The good thing is that it is something that we are discussing and I pray they finalise it as soon as possible and that's why I was talking about when we transition right now, I know there are areas that are very strong already, but we haven’t thought about the tech resource from the government side- do they have a [1:26:56 Inaudible] department? At least these tech people who will be supporting the community activities; I haven’t seen that. Do they have a strong M&E team who will be doing these quality checks for the community work? I have also not seen that I would say those are the areas that I would say they also need to think through and invest in. And for the tools that are being used, after the end of shelf life what happens-who replaces them? Or does it mean if the phones die does work stop at that? M:All right, now, how are the stakeholders at the county level, facilitating the DESC implementation? R:I don’t know what exactly the question wants M:Who is involved in the roll out of DESC? R:Those involved in the roll out of DESC... M:Yes...you did mention of...no, let me just let you answer it R:Just tell me so that I can know which one I didn’t talk about M:No [Laughter] R:Now let me tell you, in the rolling out of DESC, I would say the MOH staff and mostly County ToTs-Trainers of Trainers; so, we have county ToTs and looking even at the data points that we are collecting, I would say close to each and every Program officer at the HMTs and at the Counties...the ToTs both from the County and the Sub-County are involved; we talk about data the HRIO [Sp] is there. During the training of the CHVs there is a time she will be there in the classrooms talking about data and what we expect. We talk about RMNCH [Sp], there is...during the day we talk about family planning there is RH coordinator, the day we talk about immunization there is the AP, on the day we were talking about malaria, there are people from the lab and there is the Sub-County Pharmacists on the day we are talking about medicine So, I wouldn’t single out and say that it is done in silo or that we have just a few people that are doing it. Even looking at how the data reviews are done everyone is involved. So, it is good to involve everyone because at the end of the day each and every person has data point there close to what they are doing, that is one of their priority areas... [Inaudible 1:30:15] M:Sorry, I lost you there for a minute, I don’t know what happened R:Are you getting me? M:Yes, I am getting you but I don’t know what happened, it just went mute. You were talking about...I think like the last twenty seconds or so R:Okay, so I was saying the beauty about having all these health indicators integrated in one platform is that it keeps each and every one interested. So, they are keen to seeing what is happening and how their data is being collected and what the CHVs are doing. So, I would say in facilitating DESC and ensuring it is there everyone is keen. If we lose a phone, if it is on digitization...I have talked about that in the equipment part and everything During supervision they are also there because they want to see how data is performing, when a phone gets lost you will find them close by, there are people who are helping us work closely even with the police-the DCI department within Kisumu, just to trace-the phone got lost at this particular place, how do we get it back? So, I would say they do quite a lot and the beauty about it, it is integrated so everyone has got interest M:And how do you think funding and investment will impact the DESC implementation? R:Now this is an area that actually needs some well thought funding, not just ‘one or two’ shillings, it needs well though strategy because different counties have different number of CHVs. In Kisumu we are talking about 3,000 people. 3,000 CHVs for you...I think each and every County should just do their math depending on the areas that they want to focus on. If we are integrating all things under one roof even the better so that they have a costing analysis such that they understand the cost of having one CHV operate and what it takes But the beauty about is I always say that the county-the national government; the counties have money. We talk about mismanagement of funds, embezzlement here and there; it is just about setting priorities right. But this is something that can be done. So, during it they need to have a clear understanding on this is the minimum viable product that we want, what is its costing? How much should we plan with? How many times are we training CHVs? Is it just a one-off thing? Do we have refresher training CPS [Sp] and what’s the implication? Which ones are we using? Which software are we using-is it open source or...? We need to pay for Sustainability plan; so, it is an area that help financing, I know the County government they do their work plans. This is an area that they really need to advocate for and fight for resources especially those people who are in health. They are able to get the funding and [Inaudible 1:33:33] because if you have an integrated platform, I see different partners coming in with different tools for data collection. We are here having a digitized tool, you want people to help you mark pregnant women, why come with paper based? Why don’t you also support in the funding of this activity so that you can also be puling your data M:Just from the servers...right. How do you think the level of government engagement will impact DESC implementation? R:If those people are disengaged there is no DESC M:So, government is DESC? R:Sure; there is no level of engagement for them, they should be engaged because without ownership, I would say that it is very hard for...partners will come, they will invest, pump money for one, two, three or four years, but we look at a sustainable model. For it to be sustainable one, even before engaging they should have this thing in law. They put it in community health bill so that even coming and succeeding governments they are able to know that there is community health bill passed and this is what is expected and this is something that we should be planning and budgeting for, by default whether they are people who have interest in health or business So, I would say there is no choice there for government having levels of engagements, let partners have their different levels of engagement depending on what suits them. But because we are moving to government led-county led, it is the counties who should run the show M:Okay...how do you think the current digital health infrastructure will impact the DESC implementation? R:It is an impediment; we as partners-Living Goods; we came looking at Community Health Level One, we forgot about level two, so we were not to invest on the digital health platforms and the link facilities. Now our loop is not closed, so it means that the government needs to start thinking of having a 360 approach where we don’t forget one pocket-one is running smoothly and the other one is not. Because at the end of the day we need to see impact, [Inaudible 1:36:16] how many referrals were a closed loop and now we cannot have a visibility of that even though we pride ourselves that we are digitized, and the digitization is just ending at the community level and not this other levels M:Right, all right so you have mentioned some of these-how DESC impacts data collection standards at the county level. I just have two follow up questions on that and then we are done. How are the data dashboards affecting data collection and supervision practices? R:Yes, I would say it is not affecting data collection; that is a totally different arm. Collection is smooth and we are collecting quiet a number of data. But I think you heard me saying that sometimes we have to go to the level of requesting for this data from the back end simply because somebody has just seen that we have five maternal deaths. They are interested in knowing who these people are but they don’t have access to that back-end data, now they have to rely on me again to go and request our analyst to pull the data again for me to come back and share. So, it is a long process So, we came in as partners who were supporting community health system using digitization but our main focus was on ICCM before we shifted to eCHIS, how the dashboards were made...the key indicators on display were those that were close to ICCM and the others are just accumulations. The MOH 515 that [gate numbers? 1:38:04] but are not broken to serve the different Program Managers, officers, coordinators... So, program coordinators who cannot still visualise granular data up to the CHV and household level or data that they want, you will find that with time they will start having no interest. From where they sit, they cannot see that data till they come down to the CHV and see it on the phone or request for it from the back end. But this is an area that we have picked, we want even from the dashboard we have...whatever is being pulled for us as back-end data, all those indicators we should access them even from the dashboard So, I know the dashboard most of the time picks the one on visibility but let’s have segments of the different program areas-WASH indicators is supposed to have its own visibility, maternal indicators, nutrition indicators...all these under indicators; so that each and every person’s needs are met. Otherwise, we are slowly losing out on Program officers who cannot access the data as they would wish M:Right, now, how do you think trainings and incentives will impact the quality of data collected and received? R:Number one training is very important. I would say that for the modules CHVs are trained and CCM takes four days, you get MNCH takes two days, nutrition one day...so it is not enough. All of these modules are technical modules. So, if the days were to be longer...but again I would say longer days wouldn’t even serve them because these are adults and they will be fatigued to come for three or four-, or one-month training. We have a structure where there is continuous learning. I think would be very good for the CHVs to ensure that they strengthen their skills and they are always put on check So, this right now is an area that is not so determined, every sub-county is doing their own but at least we have regular formal training, leave alone when we do CU refreshers and even if the benefit is quarterly, at least we should have trainings focusing on one area, one technical module. That would really help support the CHVs So, on compensation to motivate them; as it is right now we thank God that for Kisumu at least they are getting some stipend, and there are counties are not getting anything. But even for Kisumu it isn’t consistent as we would want it to be. Right now, they are dating it on a quarterly basis but it would even motivate them better if it were on a monthly basis Another thing, it kills morale for the high performers, so at the end of the day provided your name was on the register you are a CHV, whether you work or not, you still get the same amount of money as the person who hasn’t worked. So kills morale for the people who work very hard Also having this to be performance based where if you know you won’t work...yes there is an amount you will get because you are a CHV but people who worked more will get an advantage over you and they will earn more. So, if we get to that point I think that would really motivate and wake up those CHVs who are just relaxed knowing that at the end of it all, we will still get the same amount M:True...so there is something that we did talk about but my recorder misbehaved, I have written a few notes on it but if you can just give just two strengths of the ECHIS strategy in Kenya-you did mention about accessibility of data and you said that a while back before digitization they used to use paper where you will have to wait till end month and then also you talked about accountability of efforts R:Yes M:If you can just maybe repeat...I know it won’t be the same but the recorder paused by itself so that I get that R:Yes, they are people who are paid by the government; they need to account the level of effort, why are they being paid? So, we have some laxity with some government staff because of their work culture and ethic that has been there over time. Because of those challenges, it is very easy for a CHA to get an excuse of not reporting. They do their own stuff knowing nobody has a visibility of what they are doing; you depend on what they tell you they have done even if it isn’t true. Hence this is also an enabler because they know at the end of it all, I will report manually and I can manipulate their reports to suit what you wanted to see But when the platform is digitised, everyone has visibility of what is happening even from the CHV level. And you know you are as good as the results you are yielding. So supporting CHVs we expect to see that on these indicators where people are reporting and this is how the report looks like. But you cannot say that you have been supporting CHVs... for example I go and have a sit down with my CHV, go door to door, do the field visits and see how the CHV is conducting her work and rectify her mistakes and leave together and expect her next time to have improved. But there is not time you can tell me that you went and walked around with a CHV but I don’t see any activities from the CHV’s end... M:It has to be uniform R:Yes; so that kind of visibility that we are able to see your level of effort-you said you supported Suka [Sp]...so and so registered this, and it is true we are seeing progress in Suka, it is something that [tallies? Inaudible 1:44:55] with the digital tool M:And access of data R:In the past the data wasn’t even being submitted in as much as it was done monthly, sometimes people had very many excuses of not reporting-I didn’t have a paper, the reporting tool; power went off so we couldn’t print, it rained so we couldn’t go and collect data. So, it would be late, not timely, not accurate...you know. But now I don’t need a CHA to go and fetch that report, the CHA won’t tell me I didn’t have transport money or that it rained or something because it is the CHV who has the report, hers is just to sync the data and everybody else can visualize. So, access has become way easy...it is easy for us to access reports fast and when needed, unlike those other times when you had event to plan before, move to the CU that is in the furthest end which is a problem to access and the terrain is not good and sometimes it is true the weather is bad or something M:Okay...how is DESC improving interoperability with KHIS? R:That's an area we are working on and I told you how easy it would be for the focal just to accept reports and they directly go where they are needed. So, it is a very efficient system that marries one another. Data moves from the community to the supervisor easily, from the supervisor to the focal till to the KHIS. Remember there are all on all the indicators that are there. So, we don’t need to have...and remember this is something that is auto-generated; auto summed depending on the activities that the CHVs had registered. So, we don’t need to have different papers here trying to aggregate chances of human errors here and there. Yes, I would say that's just about it M:Okay, so we have come to the end of our discussion R:Thank you M:I would just like to say thank you for taking time out and answering my questions. You have given me information that I know will help in bettering of the program. I don’t know, do you have any additional information that you would add concerning what we have been talking about? Or any questions R:Not really...maybe what is the end game from these interviews? M:So, the objective...okay so let me just stop this...the interview ended at 1301 END OF INTERVIEW- REVIEWING FOR ACCURACY Has the recording / transcription been verified by a second or third party? If so, please provide details Name of 2nd Reviewer: JANE ADERA Date of verification: 29/09/2022 Sign: J.A