IST-Africa 2020 Conference Proceedings

Miriam Cunningham and Paul Cunningham (Eds)

IST-Africa Institute and IIMC, 2020
ISBN: 978-1-905824-64-9

E-Surveillance for Investigating Capacity

of Health Systems to Detect and Control
Infectious Diseases of Poverty: A Case of
Kitui South Sub-County
Elizabeth M. MULI1, Francis W. MAKOKHA2, Dismas M. LUSICHI3, Carol W. HUNJA4
1,3
Technical University of Kenya, P.O BOX 52428, Nairobi, 00200, Kenya
1,3
Tel: +254 20 343672, Email: 1 emwikali@gmail.com, 3dlusichi@yahoo.com
2
Mount Kenya University, P.O BOX 342, Thika, 01000, Kenya
2
Tel: 254 722318247, 2makokhafw@gmail.com
4
South Eastern Kenya University, P.O BOX 170, Kitui, 90200, Kenya
4
Tel: +254 701070706, 4chunja@seku.ac.ke
Abstract: This research aimed to establish the capacity of the Kitui County Health
System to deal with infectious diseases of poverty including epidemics. This region
is considered arid and semi-arid and registers poverty levels of approximately 40%.
These factors contribute to a high burden of diseases of poverty hence the need to
investigate the capacity of the county health systems to detect and subsequently
control infectious diseases. The study site was Kitui South sub-county and the
medical facilities located in this region were visited and Key Informant Interviews
(KII) conducted on medical personnel and observation was used to collect data. A
web based surveillance system was created to capture the collected data. The data
was then analysed and reports generated which included the infectious diseases
ravaging the residents of Kitui South sub-county e.g. intestinal worms, amoebiasis,
and dysentery. In addition, we also noted that the medical facilities in Kitui South
have limited staffing including laboratory technicians required for laboratory
diagnosis of infectious diseases. Finally, it was evident that the facilities lacked
relevant diagnostic equipment and where available, frequent power outages hindered
the process. The findings of this study were then packaged in a web based
surveillance system, which can be accessed by stakeholders in the health sector for
informed decision making. This will assist the Ministry of Health (MoH) and the
County Government of Kitui in providing quality health services to the citizens and
achieve the goals of universal health care, which is one of the social pillars of Kenya
Vision 2030. It will also promote a centralized monitoring and surveillance of these
facilities.
Keywords: ICT, Health Systems, Surveillance, Infectious Diseases

1. Introduction and Background of Study

Globally, the improvement of health systems to overcome the challenges posed by
infectious diseases remains a priority. Sub-Saharan Africa bears the greatest burden of
infectious diseases and this intertwines with high poverty levels leading to major
inequalities when it comes to access of medical care [3]. Good health and well-being, the
third goal of the Sustainable Development Goals (SDGs), ensures a healthy population with
access to affordable and equitable health care [4]. This is bound to improve the quality of
life and alleviate poverty levels due to improved productivity, minimized costs on
treatment, reduced time taken seeking treatment by patients and caregivers, and minimized
transport costs to medical facilities.

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 One of the goals outlined in the Kenyan constitution promulgated in 2010 [5] is to
reduce marginalization through the devolution of governing structures from the national
level to county level. The constitution also provides that every person has the right to the
highest attainable standard of health, which includes the right to health care services. In line
with this, the country recognizes the need to reduce inequitable distribution of health
facilities more so in impoverished regions. In spite of the efforts by the Government of
Kenya (GoK) to improve health, a number of issues such as under staffing, inadequate
laboratory equipment that hinder effective diagnosis, poor infrastructure among others
impede the full attainment of the desired goals.
These factors contribute to a high burden of diseases of poverty hence the need to
investigate the capacity of the county health system and develop mechanisms for
monitoring the needs of these facilities. This will assist the Ministry of Health (MoH) and
the County government in decision making pertaining to staff posting, funding and resource
allocation. This study therefore investigated the capability of the Kitui South Sub County
Health Systems to diagnose the infectious diseases of poverty including reporting
epidemics. Kitui County is located in the South Eastern part of Kenya [1] and is considered
arid and semi-arid with poverty levels of approximately 40% [1].
Common infectious diseases recorded by health facilities in Kitui County include:
Malaria, Amoebiasis, Intestinal worms, TB, HIV among others. This county is served by
one (1) Government of Kenya (GOK) level four (4) hospital situated in Kitui Central, five
(5) sub-district hospitals, fourteen (14) health centres and eighty five (85) government
dispensaries all of which are sparsely distributed serving approximately 1,136,187 people
according to the census report of 2019 [2].
Infectious diseases of poverty remain a major concern in most parts of Kenya,
especially the arid and semi-arid regions that remain marginalized. Conventionally, medical
personnel in Kitui County record data manually. This data requires analysis to inform on
the status of the health systems in Kitui County. On this basis, a web based surveillance
system is required for ease of generating reports on the capacity of health facilities to cope
with infectious diseases of poverty and epidemics. This study therefore developed and
utilised this application to inform decision-making at the county.

2. Problem Statement
Kitui County registers poverty levels of approximately 40% [1] and the available health
facilities are sparsely distributed within the county thus making their access by locals
difficult. The existing systems of record keeping in these hospitals are mostly manual thus
making it very difficult for policy makers to know the actual state on the ground of these
facilities, hence hindering informed decision-making. Most of these facilities are
understaffed based on their catchment populations they serve and they also have inadequate
laboratory equipment for effective diagnosis of infectious diseases, which are prevalent in
this area.
There is therefore the need to investigate the capacity of the county’s health systems to
report infectious diseases of poverty including epidemics to ensure rapid response. Further
to this, there is need to adopt innovative ways for surveillance and monitoring of infectious
diseases in these health facilities needs to be adopted. As a result of this study designed and
developed a web based surveillance system, where this data can be conveniently accessed
in real-time and analysis can be done to generate the required reports.

3. Objectives
i) To investigate the capacity of health facilities in Kitui South Sub-County to accurately
diagnose and treat infectious diseases of poverty.

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ii) Design and develop a Web Based Surveillance system with all the findings to ensure
monitoring and surveillance of the health facilities by the Ministry of Health and
County Government officials
iii) To do the geospatial distribution of existing health facilities in the sub-county to assess
their accessibility to locals.
iv) To generate various analysis reports such as prevalence of infectious diseases of
poverty; gaps in availability of technical expertise and equipment required for accurate
diagnosis and treatment of infectious disease of poverty and level of preparedness by
the health workers to respond to epidemics of infectious diseases

4. A Brief on Current Status of the Health Sector in Kenya

As a developing country the health sector in Kenya is facing various challenges such as
slow adoption and uptake of modern technologies [4]. It is evident that Information and
Communication Technology (ICT) has become a powerful enabler in the health sector [5].
This brings about a complete turnaround to phase off the manual health systems [6] which
are slow, inefficient and exist in isolation. Currently hospital record keeping in Kitui sub-
county is recorded manually and kept in files. This makes management of records tedious
and inefficient.
Adoption and uptake of ICTs in the health sector will ensure proper record keeping of
medical records; integration of existing health systems; better monitoring and surveillance
of health facilities and hence informed decision making by policy makers. The main
objective of developing a web based surveillance system is that it can be deployed in a
distributed environment [7] to provide flexibility, seamless and a vast information sharing
platform on the health facilities which can be accessed easily by the stakeholders in the
health sector [8].

5. Technology
The web based surveillance system was developed and hosted. In addition we created a
mobile application with offline features to enable the health workers view, collect, and
share information even without access to Internet. The mobile application is mainly used by
the Public Health Officers (PHOs) who are based in Kitui Level 4 hospital where power
and network connectivity is reliable. The PHOs visit and inspect all the health facilities in
the county and during these visits they collect data from the person in charge of each
facility and this can be done using a tablet configured with the mobile application. The
PHOs later synchronize the update of the collected data when they get access to Internet.
Due to power outages and poor network connectivity in some of the facilities the offline
feature of the mobile application becomes very crucial in data collection. This also ensures
sustainability and continuous use of this intervention to ensure efficient management of
health records. Through this application data will be accessed in real-time and analysis done
to generate the required reports for timely decision-making.

6. Ethical Clearance
Although this study did not entail the direct use of data from human subjects, ethical
clearance was sought from the Mount Kenya University Research Ethics Review
Committee and permission was also obtained from the Chief Officer Ministry of Health
prior to collection of data.

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7. Study Setting
7.1 Study Design
Descriptive survey was used in this study. According to Kothari [9], this approach is
structured to examine a number of logical sub-units or units of analysis within
organizations to achieve the desired goal. The study was based on information collected
from health workers in health facilities across Kitui South Sub County. This research
employed a qualitative approach comprised of Key Informant Interviews (KII) and
observation using some checklists. During this study the researchers visited all the health
facilities located at Kitui South sub-county and the following medical personnel were
interviewed: Medical doctors, Clinical officers, Nurses, Lab Technicians and
Pharmaceutical Technologists.
7.2 Study Area and Target Population

Figure 1: Map of Kenya showing Kitui South Sub-County

The study area was Kitui South Sub-county, which is situated in the eastern part of Kenya,
with a population of about 1,136,187 people according to the census report of 2019 and
covers an area of 20,402 square kilometres (2 Million Acres). This area is inhabited by the
Kamba community and it experiences seasonal rainfall. It is a marginalized area constantly
in need of food aid and has poor health systems with majority of its inhabitants facing
inaccessible medical care. The target population mainly was medical personnel in the sub-
county specifically the Doctors, Clinical Officers, Nurses, Laboratory Technicians,
Pharmaceutical Technologists and Facility managers in both private and public facilities in
the county.
According to the World Health Organization (WHO) [3], one of the measures of
accessible medical facilities is its location within a 5 kilometre radius from the nearest
residential area. It is on this basis that this study carried out a Global Positioning System
(GPS) mapping of the existing health facilities and the catchment population they serve. In
addition, an analysis of capacity of the existing health facilities to accurately diagnose,
detect and respond to disease outbreaks was also done.

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7.3 Data Collection Tools
This study employed Key Informant Interviews (KII) and observation as the main data
collection modes. Interview questions and schedules were prepared and thereafter the data
collection exercise kicked off by the researchers. Through this, we were able to elicit in
depth responses from the respondents and this was very crucial for our study.

8. Methodology
The research adopted an investigative study and analysis of existing health facilities in
Kitui South Sub County with the aim of developing a web based surveillance system for
monitoring and surveillance of infectious diseases. This web-based system was hosted by
the Kitui Level 4 hospital and can be accessed by stakeholders such as Ministry of Health,
county government and any other stakeholders through the browser as long as they have
Internet connectivity. The mobile application with offline feature is mainly for the PHOs
during their visits and inspection to the health facilities.
The study also entailed GPS mapping and generated several geospatial maps showing
the distribution of these health facilities for policy makers to make informed decisions
when it comes to constructing new facilities, funding and allocation of resources. The study
also analysed the staffing and training needs of the health facilities; the required lab
equipment for effective diagnosis of infectious diseases and generated analysis reports on
the same.

9. Discussion of Results
9.1 Health Facility Levels and their Medical Personnel
A total of 51 health facilities in Kitui South Sub County were visited comprising Public
(GOK), Private and Mission / Faith Based with five these facilities newly constructed and
not yet operational. Out of the remaining 46 facilities, four (4) were level four (GOK)
hospitals, eight (8) level 3 health Centers (GOK); four (4) level 3B nursing homes (Private
owned) and 30 dispensaries. The data collected from the questionnaires was captured in the
web based application, analyzed and generated analysis reports as shown in the sample
table below.

Figure 2: Health Facilities categorised by level and the medical staff represented at each level

Key
M.Docs Medical Doctors
C.Os Clinical Officers
Lab Techs Laboratory Technicians
Pharma Techs Pharmaceutical Technicians
P.H.Os Public Health Offices
Table 1: Key of abbreviations in Figure 2 above

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 In Figure 2 above we note that health facilities in this area are in dire need of staff. Out
of the 46 facilities we recorded, there were only 10 medical doctors and they were mainly
found in the Level 4 government hospitals. The clinical officers (C.Os) were also present in
level 4 hospital heath Centres, and Nursing homes. The dispensaries, which are widely
distributed in number, had a single nurse in most cases that handled all the cases. Most
dispensaries lacked laboratory personnel such that most of the cases could not be handled
necessitating referral to a high level facility. The Pharmaceutical Technicians were also
few (Figure 2) and mostly in level 4 hospitals. The Public Health Officers (PHOs) in the
whole Kitui Sub County were 7 and only in the level 4 government hospitals. Below is a
graph showing this distribution:-

Figure 3: Graph showing the levels of Health Facilities in Kitui South

Most of these facilities are sparsely distributed which makes them inaccessible by the
locals. The facilities are spread across six wards namely Mutomo, Ikutha, Ikanga, Kanziko,
Athi and Mutha. The analysis below shows the number of the medical personnel across all
these facilities and can be used to inform on the additional number of medics required in
these facilities as per the WHO recommendation based on the catchment population they
serve.

Figure 4: Catchment Population and the Medical Personnel in the Health Facilities

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 Below is a graph showing this distribution:-

Figure 5: Medical Personnel by wards in Kitui South Sub County

Below are maps showing the geospatial distribution of the health facilities and additional
nurses required in these the health facilities as per the World Health Organization
recommendation.

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9.2 Prevalence of Infectious Diseases in Children

The most common infectious diseases for children both less than 5 years old and older are
shown below. Respiratory Tract Infections recorded the highest which stands at 43 cases
across the visited health facilities.

Figure 6: Map of the Prevalent Infectious Diseases for Children (both < 5 years and > 5 years old)

9.2.1 Challenges to effective Diagnosis of Infectious Diseases

Most of the health facilities in Kitui South Sub County face several challenges, which
hinder the effective diagnosis of infectious diseases. Some of the main challenges are
understaffing, lack of laboratory equipment, power outages and poor infrastructure. This
study established the following laboratory requirement needs in the visited health facilities:
LED Microscope, Centrifuge, Incubator, Hem cue (HB) Machine, Rotator (Shaker), Set up
a Functional Lab, Biochemistry Machine, Full Hemogram and Erythrocyte Sedimentation
Rate (ESR), Dual Lab Fridge, Glucometer, Lab Reagents, Doppler Machine, Bio Safety
Cabinets, RDTs, Nebulizer, Oxygen Cylinder & Concentrator, CD4 Machine (portable) and
GeneXpert Machine.
The graph below illustrates that most facilities lacked basic laboratory equipment which
hinders effective diagnosis and treatment of infectious diseases. Due to power outages in
this area the study recommends dual laboratory fridges which can be powered by either
electricity or solar energy since the facilities can make use of solar energy.

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 Figure 7: Graph showing top 20 Laboratory Equipment required for effective Diagnosis of Infectious Diseases

10. Significance and Eventual Benefits

With Universal health care as one of the social pillars of the Vision 2030 by the government
of Kenya[10] there is dire need to adopt modern technologies for collection and
dissemination of health information for easy access by all stake holders in the health sector.
The web based surveillance system will provide a platform where all the stake holders can
access up to date information on existing health facilities for informed decisions regarding
funding, staffing, and resource allocation.
As the Government also partners with investors towards achieving universal health care
there is need to monitor the progress and milestones attained. With this online platform the
investors can access and view analysis report on most prevalent infectious diseases, staffing
and training needs of the health facilities, geospatial distribution and maps of the health
facilities, required equipment for effective diagnosis of infectious diseases. The geospatial
distribution maps of existing health facilities are very crucial in identifying areas with
inadequate health facilities thus helping in the planning of equitable distribution of new
health facilities to ensure accessibility by the locals.

11. Conclusions and Recommendations

This study looked at the status of the health sector in Kitui South Sub-county and it
established that the uptake of ICT is still very low and some of the areas experience power
outages and poor mobile network connectivity. One of the objectives of this study was to
develop and host a web based surveillance system with all the findings to ensure effective
monitoring and surveillance of the health facilities by the Ministry of Health and County
Government officials in Kitui South. We also created a mobile with offline feature to be
used by the Public Health officers during their visits to inspect the other health facilities.
Since the GOK has put in place key policies and necessary strategies to enable the
uptake of technology in health, this study recommends adoption of technology in the health
sector to leverage on the benefits of ICT to the fullest in improving access and provision of
healthcare to all. We strongly believed that this approach can be scaled up to cover the

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whole county and when it succeeds it can form a model to be replicated in other counties in
Kenya. This will go a long way towards achieving provision of equitable health care
services as one of the social pillars of the vision 2030 by the Government of Kenya.

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