The ‘BOMA' Health Delivery Model An Innovative Approach to Delivering Maternal, Newborn and Child Health Services to Semi-Nomadic Communities in Hard-To-Reach Regions

www.amref.org

The 'BOMA' Health Delivery Model An Innovative Approach to Delivering Maternal, Newborn and Child Health Services to Semi-Nomadic Communities in Hard-To-Reach Regions

The African Medical and Research Foundation (AMREF) PO Box 27691- 00506, Nairobi, Kenya Tel: +254 20 699 3000 Fax: +254 20 609 518 ©2013, AMREF This document may be freely reviewed, quoted, reproduced or translated in full or in part provided the material is distributed free of charge and that AMREF is fully acknowledged. ISBN: 9789966798121 Any feedback or correspondence about this guide should be addressed to: The Country Director AMREF in Kenya P.O. Box 30125-00100 Nairobi Tel: + 254 20 699 4223 Email: [email protected] Website: www.amref.org

Layout and design: Anthony Muninzwa Illustrations:

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TABLE OF CONTENTS List of Acronyms.....................................................................................................................................................................4 Acknowledgement...............................................................................................................................................................5 Purpose of the Document..........................................................................................................................................6 1. THE BOMA MODEL: AN INTRODUCTION...................................................................................................................7 1.1. Background Information on Magadi Division and the Maasai..........................................................7 1.2 .Challenges in Delivering MNCH Services in the Maasai Community.............................................. 8 2. DEVELOPING THE BOMA MODEL................................................................................................................................ 9 2.1. Description of the BOMA Model...............................................................................................................10 2.1.1 Concepts that support strategies for health promotion in the BOMA Model..................................................................................................................11 3. KEY ELEMENTS OF THE BOMA MODEL 3.1. The Mother and Child...................................................................................................................................12 3.2. The Boma Homestead..................................................................................................................................13 3.3. The Community Unit....................................................................................................................................14 3.4. Traditional Birth Attendants.......................................................................................................................16 3.5. The Health Facility......................................................................................................................................... 16 3.6. Community-based Health Management Information System......................................................17 3.7. Linkages...........................................................................................................................................................17 4. KEY INNOVATIONS OF THE BOMA MODEL............................................................................................................ 20 4.1. Adapting the Community Strategy for hard-to-reach and semi-nomadic communities......................................................................................................................20 4.2. Inclusion of Culture.......................................................................................................................................20 4.3. Integration...................................................................................................................................................... 21 4.4 .Linking the Informal and Formal..............................................................................................................21 4.5. Male Involvement in MNCH.......................................................................................................................22 5. ACHIEVEMENTS OF THE BOMA MODEL IN MAGADI........................................................................................ 22 5.1. Increased Utilisation of Maternal, Newborn and Child Health Services by Skilled Health Professionals in line with MoPHS Guidelines......................................................................................22 5.2. Increased Community Participation and Capacity on MNCH.........................................................24 5.3. Female Empowerment............................................................................................................................... 24 5.4. Increased Partnership with the Community, Governmental departments and other stakeholders..................................................................................................... 25 5.5. Strengthening CBHMIS...............................................................................................................................25 6. LESSONS LEARNT IN THE IMPLEMENTATION OF THE BOMA MODEL........................................................ 26 7. POTENTIAL FOR REPLICATION................................................................................................................................... 27 7.1. Potential areas for replicating the BOMA Model................................................................................. 27 7.2. Steps in replicating the BOMA model.....................................................................................................27 7.3. Cost Elements of the Model....................................................................................................................... 28 7.4. Sustainability..................................................................................................................................................28 7.5. Risks and Assumptions................................................................................................................................29 8. BENEFICIARY PERSPECTIVES ON THE BOMA MODEL...................................................................................... 30

References.....................................................................................................................................................................34

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LIST OF ACRONYMS AMREF ASAL CHC CHEW CU CHW DCHS DHMT TCML CBHMIS TBA MNCH MDGs ANC MOH FGM FGC KWS NHSSP II WASH UFBR c – IMCI ORT LLITNs FHMC IECs HRH BCC

African Medical and Research Foundation Arid and Semi Arid Region Community Health Committee Community Health Extension Worker Community Unit Community Health Worker Department of Community Health Services District Health Management Team TATA Chemicals Magadi Limited Community Based Health Management Information System Traditional Birth Attendants Maternal, Newborn & Child Health Millennium Development Goals AnteNatal Care Ministry of Health Female Genital Mutilation Female Genital Cutting Kenya Wildlife Services National Health Sector Strategic Plan II Water, Sanitation and Hygiene Unite For Body Rights Community Integrated Management of Childhood Illness Oral Rehydration Therapy Long Lasting Insecticide Treated Nets Facility Health Management Committee Information, Education and Communication Human Resources for Health Behaviour Change Communication

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ACKNOWLEDGEMENT AMREF would like to thank the Magadi community for their support and participation in the Magadi MNCH Project within which the BOMA model was coined and implemented. Your commitment and sharing of best practices contributed immensely to the success of the BOMA model. We also thank our partners; the TATA Chemicals Magadi Limited, the Magadi Hospital, the Ministry of Public Health and Sanitation through the, Kajiado North District Health Management Team led by Dr. Marion Mukira, the Magadi Provincial administration led by Senior Chief Joel Sayianka, and the Kenya Wildlife Service led by Sergent Berret Wichuli for their support and commitment in the implementation of the BOMA model. Sincere gratitude to all the Community Health Workers, members of the Community Health Committees, Facility health Management Committees and Community Health Extension Workers led by the Divisional Public Health Offficer, Paul Sayianka for tirelessly working with the communities within the BOMAs and community units. The success of the BOMA model is likewise attributed to the commendable work done by the Magadi MNCH project implementation team namely;, Dorcus Indalo, Josephine Lesiamon Stephen Mwangi, Peter Sarinjore, Charles Leshore, and Robert Athewa. We acknowledge the leadership and support of the AMREF Kenya country director, Dr. Lennie Bazira S. Kyomuhangi, Dr. Meshack Ndirangu, deputy country director, Peter Ofware, programme manager and Dr. David Ojakaa, programme manager. We recognise and acknowledge efforts of the following AMREF staff in documenting and editing the BOMA model; Susan Olang'o, Laura Swanson, Janice Njoroge and Antony Muninzwa. Finally, we take this opportunity to sincerely thank AMREF Netherlands and AMREF Austria for providing financial and technical support to the Magadi Integrated MNCH project. “The best a mother can give her children is her empathy, her presence, her ever nourishing love, her forgiveness and herself” “A mother is someone, who dreams for you, but lets you chase the dreams you have for yourself and loves you just the same'' I highly appreciate and respect mothers who took the initiative, despite the challenges they face to make a difference in their family lives.” -Dorcus Indalo

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PURPOSE OF THE DOCUMENT The BOMA Health Delivery Model has been developed by AMREF Kenya, in partnership with Kajiado North District Health Management Team (DHMT) and TATA Chemicals Magadi Limited (TCML) to promote Maternal, Newborn and Child Health (MNCH) within semi-nomadic pastoralist communities in hard-to-reach regions. This document presents a comprehensive description of the BOMA model, key innovations, successes and the lessons learnt in Magadi area. Importantly, this document provides other agencies the opportunity to learn from AMREF's experience among the Maasai pastoral nomadic communities in Magadi and apply the BOMA model in future projects targeting similar communities. Agencies delivering the Community Strategy or other primary health care services in hard-toreach semi-nomadic communities will find this document to be a useful guide for designing and implementing successful programmes that encourage community partnerships and participation at the household level.

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1. THE BOMA MODEL: AN INTRODUCTION Although Kenya has made tremendous progress in reducing childhood deaths, maternal and neonatal mortality remains unacceptably high. Whereas infant mortality decreased from 77 per 1000 live births in 2003 to 52 in 2008, neonatal mortality has almost stagnated over the last ten years at about 30 deaths per 1000 live births contributing to 60% of child deaths. Likewise, maternal mortality increased to 488 per 100,000 live births in 2008 compared to 410 in 2003. Kenya's success in reducing childhood deaths has largely been attributed to government and development partners' efforts in improving immunisation coverage and use of insecticide treated bed nets. However, these gains are not uniform across the country, with hard-to-reach regions often experiencing higher maternal and child mortality. Magadi Division, in Kajiado North District, is an example; a hard-to-reach region that has recorded high maternal and child mortality and poor MNCH indicators. An arid and semi-arid lands (ASAL) region Neonatal 37/1000 31/1000 about 120km south west of Nairobi, Mortality Rate Magadi has a population of approximately Under fives(U5) 80/1000 74/1000 mortality rate 25,500 (Census report 2009), Under fives(U5) predominately Maasai. There are a number 24.5% 44% mortality rate of challenges in delivering maternal, 52.4% 44% Four ANC Visits newborn and child health (MNCH) services 500/100,000 488/100,000 to Maasai communities in Magadi Division, Maternal live births live births Mortality Rate including poor infrastructure, harmful (estimate) cultural beliefs and practices, distance to health facilities, and inadequate staff and equipment, among others. Table One: MNCH Status in Magadi, Compared to National Averge Magadi National Division Average

1.1.

Background Information on Magadi Division and the Maasai

Magadi division is one of the four divisions within Kajiado North District and is located in the south west of the Republic of Kenya. Magadi is classified as a hard-to-reach region and is primarily arid grasslands that experiences both flash flooding and regular water shortages. Transport, roads, communication networks and infrastructure in the region is poor, with many areas hard to reach by road. Magadi division is predominantly occupied by the Maasai with non-Maasai mainly settled in the farmlands of Nguruman, Magadi Township and in other trading centres. The Maasai are semi-nomadic pastoralists that live in arid and semi-arid regions throughout Southern Kenya and Northern Tanzania. Maasai culture is often described as strongly conservative, patriarchal and monotheistic, and despite pressures from modern

KAJIADO

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society,the Maasai continue to observe long-held beliefs, values and cultural practices. Gender relations between men and Maasai Age Sets and Moran women are also culturally-bound. Maasai The community is highly-structured through generational communities are often polygamous, age-sets and cultural leadership structures. Young men are where one man marries multiple women. bound to one another through their age-set – a group of males who were circumcised at the same time. After Female genital mutilation (FGM) is circumcision, the males become 'Moran', the traditional practiced as a rite of passage from Maasai warriors. Once the Moran return to the community girlhood to womanhood, and indicates a and marry, they move into the next stage as cultural elders. woman's eligibility to marry. Traditional birth attendants (TBAs) are the custodians of culture, and are responsible for both assisting with birth and ensuring women are circumcised. Women and girls are socialised to be passive – they often have little decision making power and their purpose within Maasai culture is to bear children and look after the Boma/homestead. Men control about 70% of the family expenditure with women controlling about 25% and other members of the family, mainly sons, control the rest. Men own all livestock, while livestock products like milk and manure belong to the women. Women control only a limited range of activities and have restricted access to decision-making in the community. This limited access to financial resources and decision making has direct implications on the health of the women and their children. Table Two: Magadi Division Demographic Summary Area Land classification Total population Children under five years Women of child-bearing age Population density Source of livelihood Poverty index HIV Prevalence School enrolment Average yrs of formal education*

2,640 sq kms Arid and Semi Arid Lands 25,500 people 5,368 7,578 9.7 persons per sq km Livestock, irrigation farming, horticultural products 45% 4.1% Girls – 35% Boys – 65% Less than 3.5 years

References: Kajiado North 2009 Census and DHIS projections, *2001 socioeconomic survey of Olkiramatian and Shompole group ranches

1.2.

Challenges in Delivering MNCH Services in the Maasai Community

There are a number of challenges in delivering MNCH services to Maasai communities in Magadi Division (see Table Two). These are all compounded by the fact that the entire division has only one hospital (the private Magadi Hospital run by TCML), one health centre and eight dispensaries. Two of the dispensaries are not operational due to lack of personnel Table Two : Challenges in Delivering MNCH Services in Magadi Community Challenges ? Low literacy levels ? Low school enrolment of girl children ? Lack of exposure to the health system and health education ? Nomadic and semi -nomadic migration

Traditional Cultural Practices ? Early & forced marriage ? Female genital mutilation (FGM) / cutting ? Limiting dietary intake amongst pregnant women, resultin g in underweight babies, anaemia and nutritional complications

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away from services in search of water and ? High reliance on unskilled traditional birth pasture. attendants (TBAs) ? Gender dynamics Inadequate Health Facilities Poor Infrastructure ? Inadequate supplies and equipment ? Poor roads and transport networks ? Health worker shortages ? Poor communication networks ? Poor referral systems ? Inaccessible health facilities

2. DEVELOPING THE BOMA MODEL In response to the situation in Magadi, AMREF Kenya launched the MNCH Magadi Integrated Health Project in 2005. Funded by AMREF Netherlands and in partnership with the Kajiado North District Health Management Team (DHMT) and TATA Chemicals Magadi Limited (TCML), the project developed an innovative approach to deliver MNCH services to the semi-nomadic Maasai community in Magadi: the BOMA model. The BOMA model was designed in 2005 in partnership with AMREF project staff, Kajiado North DHMT, the Ministry of Health, provincial administration and community leaders, as an appropriate approach to reach women and children, the target beneficiaries. The first phase was launched in 2005, with a second phase commencing in 2010 to 2013. Phase One of the project was co-funded by AMREF Netherlands and AMREF Austria between 2005-2009 at €345, 108 and Phase Two was funded by AMREF Netherlands at €570,000. The BOMA model identifies the Maasai homestead, known as a 'Boma' in Swahili or 'Enkang' in Maa, as the ideal interface between the semi-migratory community and MNCH health care delivery and focuses on developing linkages between the community and Levels Two, Three and Four of the health care system. AMREF has been working with Maasai communities in Magadi Division since the early 1960s, providing curative health ser vices through mobile clinics, community-based healthcare interventions and management of the Entasopia Health Clinic (see Assessing 50 Years of AMREF's Intervention in Kajiado District, Kenya for further information). While the mobile clinics were effective in delivering services to a semi-nomadic Dr Rees attending to an elderly Maasai man community, they proved costly and unsustainable. Thus, from the mobile clinics evolved an alternative, innovative approach to address the poor MNCH status and to empower the community itself to establish and strengthen health services. Through the BOMA model, the first phase of Magadi Integrated Health Project addressed five core areas, namely: Maternal Child Health (MCH), Adolescent Sexual and Reproductive Health (ASRH), School Health, Water and Sanitation and Trachoma. This was followed by phase two commencing in

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2010, focusing mainly on Maternal, Newborn and Child Health (MNCH). The goal of the MNCH Magadi project through the Boma model is to contribute to the attainment of Millennium Development Goals (MDG) 4 and 5 of reducing child mortality by 2/3 and maternal mortality by 3/4 in Kenya. To this end, the project seeks to achieve the following objectives: i. ii. iii.

Increased utilization of maternal newborn and child health care services provided by skilled health professionals in line with MoPHS guidelines. Improved case management of childhood illnesses at community and health facility To strengthen community health information system and link it to health facility information system

2.1.

Description of the BOMA Model

The 'Boma' or 'Enkang' forms the lowest structure in terms of leadership in the Maasai culture and this therefore is viewed as an ideal interface between the semi migratory community and the other levels of health care delivery. The model was originally named the Manyatta model, however this lead to Why Boma? community confusion as the manyatta refers to both an individual household The eldest person in the Boma is the within a Boma and a temporary structure ultimate decision maker and takes built for special ceremonies and cultural responsibility for the Boma. The Boma events. The model was then renamed as the model was meant to make the Boma BOMA model in 2007. The BOMA model Head see health as part of that seeks to fit in with local structures and authority. traditions to change health behaviour, aspects of Maasai culture that positively influence health promotion and partnering with existing community structures to address cultural barriers to health. The Boma Homestead Homestead – ‘boma’ (Swahili) or ‘Enkang’ (Maa) The Boma is a traditional Maasai homestead that consists of a closely knit family, friends or people who have come together for security reasons. The Boma typically consists of four to ten households within a defined, fenced space. Each household houses a wife and her children, or the grown sons of the Boma head. There are also fenced pens within the Boma for livestock, usually cattle, goats and sheep. Total authority is vested in the eldest person (usually men or women in some cases) who takes responsibility for the Boma.

Women are responsible for building the houses, known as manyattas in Swahili or enkaji in Maa, and all duties within the Boma. The eldest man, or Boma head, has control over all decision-making and resource allocation. The Boma head is the gatekeeper within the Boma and often a cultural elder within the wider community.

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2.1.1. Concepts that support strategies for health promotion in the BOMA Model Socio-ecological model: The Boma model is in line with the social ecological in public health which recognizes that individual behaviour is influenced by a range of personal, relational and social factors model (Dahlberg LL & Krug EG, 2002). Multiple strategies must therefore be employed at the various levels simultaneously in order to achieve social change. Social Organisation and Social Structure: The BOMA model takes cognisance of the organisation of the Maasai into Bomas and distinguishes the Boma as the unit of operation. Most significantly, the model recognises the status and authority vested in different structures within the Maasai community such as Boma heads and elders and identifies these structures as entry points to influence decision making on health issues in households. Social Networks and Social Institutions: The BOMA model builds on the strong social networks and social institutions important to the Maasai community such as TBAs, traditional healers, elders, morans, health facilities, community units, schools, provincial administration, religious institutions, TATA Company, markets etc. Social Stratification: The Maasai community is patriarchal, which means kinship and decision making follows the male lineage. Further, the community is organised into age sets with privileges bestowed upon certain age sets such as morans and elders. The BOMA model uses this stratification as an opportunity to promote male involvement, influence behaviour change and advocate for empowerment of women.

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3. KEY ELEMENTS OF THE BOMA MODEL There are seven key elements of the BOMA model: 1) mother and child 2) Boma/homestead 3) Community Unit 4) Traditional Birth Attendants (TBAs) 5) Health Facility 6) Other Community Linkages 7) Community-Based Health Management Information System (CBHMIS). Figure 1 : Conceptual Illustration of the BOMA modelin the form of a Maasai necklace

3.1.

The Mother and Child

The ultimate target of the BOMA model is to improve the health of women and children in the Maasai community by improving their knowledge, attitude, behaviour and practices on health. However, to influence their uptake of key health services such as ANC, skilled deliveries, immunisation etc, the model influences the attitude and decisions of the household and Boma heads as well as all other relevant social

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institutions. Within the BOMA model, women receive education and social support on the importance of Family Planning, importance of Antenatal Care, Counselling on care of pregnant mothers, importance of skilled deliveries, Prevention of Malaria in Pregnancy, Education on care of newborn, and the importance of postnatal care, as well as the other health-promoting services as described in section 3.2 below.

3.2.

The Boma/Homestead

The Boma is at the heart of the model. The BOMA model identifies the Boma as the key site of MNCH interventions within the community and maximises on the authority ascribed to the Boma head to influence decisions on health across the homestead. The Boma Head is the entry point to the households and community. Through the model, men attend a half day sensitisation meeting on MNCH issues that seeks to promote male involvement and support for MNCH issues within the Boma. The model is anchored on the hypothesis that once the Boma head buys in to a position; the other members in the Boma are likely to follow. By targeting one, the model aims to reach many. The Boma is the site of a number of practical health-promoting interventions, which include: i. Demonstration and distribution of Insecticide-treated nets (ITNs) for pregnant mothers and under-fives in each household. Most houses within the Boma have two beds, which are both furnished with ITNs. The model promotes a household approach to the distribution of nets to address the seniority concept in which men get most preference. ii. A leaky tin and soap near the pit latrine to promote personal hygiene iii. A pit latrine constructed at an appropriate site within the Boma using locally available materials and a screen-covered ventilation chimney iv. A compost / refuse pit v. A dish rack vi. Demonstration and distribution of Aquatabs to each household within the Boma for water treatment vii. Mother and Baby card for Mothers and Children under five years. Mothers are followed for immunisation and vitamin A until the children turn five. A number of other adjustments to the Boma are also encouraged, including separating animal and human areas with fences to control flies and reduce cases of trachoma, raising fireplaces to prevent child burns, and increasing window size to improve lighting and ventilation to reduce respiratory tract infections.

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Figure Two: An illustration a Maasai Boma developed by school children for replication

3.3.

The Community Unit

The Kenya Ministry of Health's Community Strategy launched in 2006 is aimed at empowering Kenyan households to take greater control of their own health by recognising the community as LEVEL ONE of service delivery (MoH, 2006). The Community Strategy is implemented through community units composed of an average of 5000 people or 1000 households. In the context of the BOMA model, a community unit is composed of 150 – 200 Bomas or approximately 1000 households a s p e r t h e Co m m u n i t y S t r a te g y. Community Health Workers (CHWs) are central to ser vice deliver y within community units and act as a link between the Boma and health facilities. They are chosen from the community and by community members in public barazas in line with the Community Strategy Community Health Committee Member giving a health session operational guidelines and trained on the community strategy. CHWs serve approximately 20 households or 100 people, usually contained within two to four Bomas including the CHWs own Boma of residence. A Boma consists of an average of 6 households with some having up to 10. While national guidelines changed in 2009 to allocate 50 households per CHW, the geographical distance between Bomas in Maasai communities makes this unfeasible. In each Boma, CHWs are responsible for engaging the Boma head and garnering his permission to support health interventions within the homestead. Women within the Boma are responsible for taking care of all household duties thus, once approval from the Boma head is received, the CHWs work with the women to educate them on healthpromoting behaviours and implement various interventions (as listed in section 3.2 above).

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The CHWs work closely with the women to: ! Provide information on Maternal, Newborn and Child Health (MNCH), including the

importance of four antenatal care (ANC) visits and delivery by a skilled attendant ! Deliver health education on water and sanitation, malaria, nutrition and basic health

issues ! Identify danger signs in pregnancy, newborns and children ! Encourage routine immunization for newborns and children under five years ! Empower communities to seek services and provide referrals to the nearest health

facility ! Follow up referrals, with advice from the Community Health Extension Worker

(CHEW) ! Organise Community Dialogue Days and action days, as per the Community Strategy

To enable CHWs perform the above tasks effectively and efficiently, they undergo continuous trainings on the community strategy, health promotion, communicable diseases control, Child Care and the sick child, chronic diseases such as Tuberculosis, Reproductive Health, Community based Maternal and Newborn care, Nutrition, Sanitation etc. The CHWs are also provided with reporting tools including CHW household registers (MOH 513) and CHW Service Delivery Log book (MOH 514) and bicycles to facilitate referrals and home visits. Motivation of CHWs is key and hence the model supports CHWs to initiate income-generating activities, provides them with identification materials such as badges and certificates. Other important structures that are trained within the community unit and engage with the Bomas include the Community Health Committee (CHC) and the Community Health Extension Worker (CHEW). The CHC is the governance wing of the community unit and provide oversight support to CHWs, including resource mobilisation. Each village is assigned a CHC member alongside a particular number of CHWs. CHEWs on the other hand are MoH staff and provide technical support and backstopping to CHWs. They are the link between the CHWs and the health facility. 3.3.1. What value does the BOMA model add to the Community Strategy? The BOMA model is implemented in line with the community strategy except that it focuses on Bomas whereas the community strategy focuses on individual households when establishing community units. The focus on a Boma as one cohesive unit ensures that all households within the Boma are covered by a CHW without fragmentation. It also facilitates easier follow up of the nomadic community when they migrate in search of pasture since the CHW is able to keep track of the Boma. Because the BOMA model holds the Bomas as one unit, CHWs are able to support one another. For instance, a CHW can request another CHW to take care of the Boma when he/she is away.

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3.4.

Traditional Birth Attendants

As the primary custodians of Maasai culture, TBAs have traditionally supervised births and conducted deliveries within the homestead. They are often the second decision maker after the Boma head, highly accepted by women and an important gatekeeper and source of information regarding MNCH issues. Rather than deny TBAs position within communities, AMREF's BOMA model engages TBAs in a new role as 'delivery companions'. Through training and sensitization, TBAs are exposed to information on pregnancy risks and complications, provided education on skilled attended deliveries and are oriented to maternal wards through health facility visits. In their new role, TBAs partner with CHWs and health facilities to: ! Encourage early initiation of ANC visits and refer women to health facilities ! Demystify cultural and social myths surrounding pregnancy and childbirth ! Provide education on nutrition, hygiene and malaria prevention ! Accompany women to health facilities for skilled attendant deliveries ! Share information with CHWs ! Inform community chiefs of recent births to be registered with the government ! Advocate for alternative rites of passage to Female Genital Mutilation (FGM) Traditionally, TBAs are compensated for their work through small rewards, such as a goat or cash. When TBAs escort women to facilities for skilled attendant deliveries, the BOMA model encourages health facilities to use part of the user fee charged to reward TBAs and encourage future referrals.

3.5.

The Health Facility

The health facility is key for referrals and treatment. The model builds the capacity of health facility staff on emergency obstetric care and early identification of emergencies to enable them respond effectively to the demand created at the community. Health facility staff work together with CHWs to promote uptake of MNCH services such as ANC, skilled deliveries, immunisation and good nutrition practices. They work with the CHWs to conduct outreach services to remote locations to improve access to essential services such as immunisation.

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To compliment the work of the government, AMREF constructed a health facility in Entasopia to increase Waiting Bomas are access to health services. Being a hard-to-reach area, constructed at the Magadi has few health facilities and the only hospital facility to encourage available is a private hospital belonging to TATA women who are Company. This need has promoted public private almost due to deliver partnerships in which TATA subsidises treatment costs at the health facility for local residents. Similarly, to counter the poor road network, AMREF, TATA and the Ministry of Health work together to ensure vaccines are delivered to facilities on time using the company train or AMREF and TATA vehicles. Through public private partnership, CHWs use the TATA company train to refer patients from distant locations.

3.6.

Community-based Health Management Information System

Community-Based Health Management Information System (CBHMIS) is a system of collecting and disseminating community health information for better health planning and decision-making. As per the Community Strategy, CHWs use the household register to collect information from the households. This is then recorded and analysed at the community resource centre, with data disseminated to both the community through the Community Chalkboard at the nearest health facility and the DHMT for monitoring and planning. The model has incorporated electronic CBHMIS in two community units to improve collection, analysis and use of information. CHWs, CHEWs and CHC are trained on how to use the system and interpret information generated for decision-making. A good CBHMIS provides a basis for setting benchmarks, managing performance of community programmes and assessing impact.

3.7.

Linkages

The final component of the BOMA model is the emphasis on linkages: with the local administration, project partners, local community structures and schools. While the first four components are intervention components, linkages are a key implementation component of the BOMA model. The scope of linkages is outlined in Table Four.

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Table Four: Key linkages within the BOMA model in Magadi Stakeholders Local Administration (Chiefs, Assistant Chiefs,)

Scope of Community Linkages ? Encourage and facilitate community mobilisation and buy-in ? Involvement in stakeholder meetings, Dialogue Days, training events ? Representation in CHC ? Information sharing, including access to community mapping ? Enforce government policies Community structures ? Ownership ? Community mobilisation (Community elders, rites ? Champions for Behaviour change of passage e.g. FGM, ? Addressing cultural barriers to health promotion Morans) Project Partners (Kajiado North DHMT and TCML) Schools

? Encouraging community mobilisation and sustainability ? DHMT recruits, trains and supervises CHWs ? TCML provides subsidised community access to the private hospital and cold-chain vaccine transportation ? Sensitise youth to health interventions, e.g. leaky tins ? Encourage students as early-adopters, to model changes in boma ? Provide channel for information distribution into boma, e.g. dates for next ANC visit as literacy levels are low amongst mothers. ? Promote alternative rites of passage

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4. KEY INNOVATIONS OF THE BOMA MODEL There are five key innovations that set the BOMA model apart from a standard community unit.

4.1.

Adapting the Community Strategy for hard-to-reach and seminomadic communities

Unlike urban areas where households are geographically close and can be neatly divided amongst CHWs, CHWs in the BOMA model are responsible for two to four Bomas, based on their proximity to one another. As such, some CHWs serve more households than set out by the community strategy, while others may serve less. The BOMA model has also been designed to Community Innovations ensure community migration does not During times of migration, the CHW will notify the disrupt access to health services. CHWs are health workers of the movement and new location. responsible for their own Boma first, and if Health workers are therefore able to take mobile services to the new location, which is often around migration does take place, it is common for a a water point. CHWs also travel with their own number of Bomas to relocate together boma an d continue providing services to them. making it easy to track them. The CHW When only part of the Boma moves or the CHW has therefore travels with the community, and to be away, he/she coordinates with other CHWs to take of the Boma. households are easily traced as Boma members travel together. In Magadi, when a Boma migrates without a CHW, it is not uncommon for the current CHW to contact a CHW in the new location and 'handover' the households to the new CHW.

4.2.

Inclusion of Culture

In the BOMA model, culture is not merely a factor to be considered, or a barrier to be overcome, but actively included and accommodated in the model. This is vital when working with Maasai communities, whose cultural traditions determine every aspect of life, and is evident in the model's focus on the boma rather than the individual household. The BOMA model has gained greater access to women and children, and ensured community buy-in at all levels, which is essential to empowering communities to take greater control of their own health.

“Why the BOMA model is successful is because it has accommodated culture.”

Charles Leshore, Project Assistant Magadi MNCH

AMREF recognises that there are some harmful Maasai cultural practices that are a barrier to good health. However by working within the culture, the BOMA model has gained greater acceptance within the community to partner with community-based change agents to sensitively address myths and negative practices.

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4.3.

Integration

The BOMA Model adopted an integrated approach to health. Phase One (20072009)included integrated water, sanitation and hygiene (WASH) interventions, Trachoma control, and behaviour change. Phase Two integrated alternative rites of passage to FGM through AMREF's Unite for Body Rights Project and drought response programme to address famine and food security. 4.3.1. Sexual and Reproductive Health The BOMA model has been integrated with Community Innovations AMREF's Unite for Body ? Women often use beads to conceal marks from Rights (UFBR) project to hormonal implants deliver sexual and ? Health workers use market reproduc tive health days to give appointments for family planning clinics to services in Magadi. The make it easier for women to UFBR Project aims to attend and due low literacy improve the sexual and levels reproduc tive health (SRH) and rights of nomadic youth through increased utilisation and quality of SRH services and Comprehensive Sexuality Education (CSE), the reduction of sexual and gender based violence (SGBV) and increased acceptance of sexual diversity. Using the BOMA model's community linkages, CHWs and TBAs, the UFBR has delivered family planning training through CHWs and peer educators and engaged various community members through mother girl forums, cultural elder forums and forums with youngmothers 'isiangikin' forum. Significantly, the UFBR has also developed and implemented an Alternative 4.3.2. Emergency Health Care In many nomadic and hard-to-reach communities, community members have to travel long distances, usually by foot, to reach the nearest health facility, creating challenges in delivering emergency health care. In response to this need, AMREF and TCML developed an innovative solution – the Magadi Train Ambulance. CHWs are each given a special board, which they can use to flag down the TCML train when a community member presents with an emergency health issue. The use of CHWs, community mobilisation and partnerships within the BOMA model can also be harnessed for greater service access in the region.

4.4.

Linking the Informal and Formal

A second unique innovation is the incorporation of TBAs into the formal health system to ensure greater access to and uptake of health services. While official health policy has actively excluded TBAs from service delivery, AMREF recognised the influence TBAs hold over maternal health behaviours and their potential to influence better health outcomes. The BOMA model both capitalises on the strong relationships TBAs have with the community and empowers TBAs to better serve their communities.

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4.5.

Male Involvement in MNCH

The BOMA model is also innovative in the way it engages men in issues of MNCH. Both CHWs and TBAs are able to engage Boma heads and other men, building their knowledge of pregnancy risks and health issues in the community and sensitising them to the importance of ANC and skilled attendant deliveries. Male involvement in Dialogue Days and other stakeholder forums reinforces key messages.

A husband accompanies his wife to the clinic

5. ACHIEVEMENTS OF THE BOMA MODEL IN MAGADI The MNCH Magadi project, through the implementation of the BOMA model, has achieved a number of significant successes in increasing utilisation of MNCH, improving case management of childhood illnesses and strengthening CBHMIS in Magadi District. Moreover, the project has contributed to increased community mobilisation, female empowerment and community participation in health service delivery, highlighting the suitability and potential of the BOMA model. 5.1.

Increased Utilisation of Maternal, Newborn and Child Health Services by Skilled Health Professionals in line with MoPHS Guidelines The project achieved significant increase in the utilisation of MNCH services (see Table Five). Where indicators were poor in Phase One, the project responded with an enhanced response and the inclusion of TBAs into the BOMA model with the goal of improving MNCH. Outcome

Indicator

Baseline 2007

ETE 2013

4.1% 20.1%

ETE 2009 / Baseline Phase Two 32.1% 14.8%

By 10% from 4.1% By 10% from 20.1% baseline

4 ANC visits Skilled attended deliveries

By 20% from 28.2% at baseline by 20% from 68.9% the baseline

PMTCT

28.2%

49.1%

81.0%

U5 ITN use Mothers (ITNs)

68.9% 65.2%

67.1% 81.7%

69.6% 78.5%

by 30% from 40.6% baseline by 10% from 68.4 % at baseline

FP uptake

40.6%

32.1%

31.2%

Vaccination coverage

64.3%

71.2% (U 12 months)

Baseline 68.6%

TT coverage

68.4% (KHIS:M 44.5%) 68.6%

87.9%

86.4%

Phase One Target

Increased ANC Increased skilled attended deliveries Increased HIV testing Increased U5 sleeping under ITNs Increased uptake of family planning Increased immunisation services U5 Increased TT

Phase Two 59.4% 23.8%

The BOMA model improved early initiation of ANC (22.4% to 29.45% in first trimester). Majority of the mothers (90.8 percent) also commenced breast feeding within an hour of delivery and a third (30.9%) reported exclusive breast feeding among children of less than 6 months. The ETE finding on exclusive breast feeding in Magadi compares favourably with the national average of 32% (KDHS 2008-09).

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A Mother's Story The real impact of the BOMA model is evident in the lives of Magadi's women and children, such as Lanet Saga and her son. Like manyMaasai women, Lanet gave birth to her first child in the traditional Maasai way; at home, without the support and supervision of a skilled delivery attendant. However, during her second pregnancy, Lanet received vital education from a Community Health Worker, Esther Leshoko - her mother.

Lanet and her son at Shompole Dispensary after receiving child immunisations.

“When I was pregnant with my 2nd baby, I was taught by a CHW, who is my mother, to attend antenatal clinic, which I did. I went to Magadi Hospital when I was 4 months. They took my blood and urine and I was told I didn't have enough blood. I went there 6 times before giving birth.”

Anaemia is a common condition among pregnant Maasai women, due to poor eating habits during pregnancy occasioned by food taboos and incorrect nutrition advice from TBAs. As a result of the MNCH Magadi Project, women throughout Magadi have been encouraged to access and utilise antenatal care. In 2007, just 4.1% of women accessed their recommended four ANC visits. By 2009, that had jumped significantly to 32.1%. In the final two months before she gave birth, Lanet decided to stay with her husband, who works for TCML, in Magadi Township. When labour started at 9pm one Saturday night, it marked the beginning of a new experience for this mother – she was going to deliver in a health facility under the supervision of a skilled delivery attendant. “[I] was taken to Magadi Hospital and delivered well on Sunday 3pm. My health and that of my baby was good. I stayed in the hospital until Monday 1pm and discharged.” Traditionally, Maasai women give birth at home with the support of an unskilled Traditional Birth Attendant (TBA) contributing to high mortality rates and disability. The BOMA model has reoriented TBAs to new roles of advocating for skilled attendant deliveries and escorting pregnant women to the health facilities to deliver. Through the work of CHWs and TBAs, the MNCH Magadi project has seen skilled attendant deliveries rise, from 14% in 2009 to 20% in early 2012. As a result of further education and support from the CHW, Lanet exclusively breastfeed her child for the first six months of his life. She made sure she ate well, to ensure she had enough milk for her son. “My baby has never had diarrhoea or any illness. I know breastfeeding a baby for 6 month is good and I urge other Maasai mothers to do the same.” In Lanet's eyes, the results speak for themselves – a happy, healthy mother and a happy, healthy baby. Lanet's story is just one of the inspiring successes of the BOMA model.

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5.2.

Increased Community Participation and Capacity on MNCH

A major and significant achievement of the project is increased community mobilisation and capacity building across various levels of the community in Magadi. To date, the project has: ! Supported the establishment of eight Community Units (CUs) and trained 268

! ! ! ! ! !

CHWs, including 102 female CHWs, who serve 5500 households in 520 boma homesteads Strengthened eight Facility Health Management Committees (FHMC) Sensitised 300 Traditional Birth Attendants on their new roles of referral and escorting mothers for skilled deliveries Held 236 Community Dialogue Days and conducted 116 community outreaches Trained 22 members of provincial administration (chiefs and assistant chiefs) on the Community Strategy and community based maternal and child care 3500 men adopting positive child survival practices Distributed 2000 Long lasting Insecticide Treated Nets (LLITNs) to prevent malaria

The project has lead to increased community participation in decision-making and health service delivery. When challenges have risen, the model has empowered the community to respond innovatively (see insert, right). Through the project, regular dialogue days have encouraged greater community participation, and women's involvement in barazas and other community meetings has increased.

5.3.

Community Innovations After learning about the risk of crossinfection during cross-border migration from Tanzania, CHWs have actively engaged Tanzanian migrants to check that their children have been immunised and escort them to local health facilities in case they are not immunised.

Female Empowerment

Though traditionally women have very little decision-making power, through the BOMA “Women can now speak on issues model women are engaged and empowered to like FGM and forced marriage. adopt health-promoting changes within the They go to meetings and Boma. TBAs are empowered to encourage fellow participate equally in decision making in the home”. women to change their attitude and health Alice Saruni, beneficiary seeking behaviours during pregnancy, childbirth and postpartum periods. Through education and experience, women are able to participate in health decisions, speak up in public barazas, garner support from male gatekeepers and adopt sustainable health changes within their homestead.

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5.4.

Increased Partnership with the Community, Governmental departments and other stakeholders

The BOMA Model is implemented in a partnership model with the Kajiado North District Health “I have been involved in Management Team (DHMT) and TATA Chemicals implementation of the BOMA Magadi Limited (TCML). Through this partnership, model since 2007, having been the capacity of the DHMT to coordinate health one of the first CHEWs to be activities in the region was strengthened. Health trained on the community activities in the division are effectively coordinated strategy. We work hand in hand through a regular divisional stakeholders forum with AMREF who facilitate and that includes a wide range of stakeholders. DHMT implements. This is a AMREF also partnered with TATA Chemicals Magadi positive partnership”. Limited (TCML) to deliver the MNCH Magadi Paul Sayanka, DPHO and CHEW Project. With a strong focus on sustainability and corporate social responsibility, TCML provides highly-subsidised health services to the community through the private Magadi Hospital. The relationship builds on previous partnerships, where TCML was involved in setting up Entasopia Health Centre and restoring the water pipeline. The health center has since been handed over to the community.

5.5.

Strengthening CBHMIS

The AMREF CBHMIS model has been integrated in 5 CUs implementing the BOMA model in Magadi and two functional community resource centres established. As a result, the Maasai CHWs are able to collect health data at household and community level, analyze and give feedback to the community for action. Community chiefs and leaders have been empowered by the data collected and analysed by CHWs, allowing them to improve community planning and food distribution. For instance, the chief uses data from the CBHMIS to aid food distribution. TBAs also share updates regarding recent births with community leaders, allowing them to register the children with the government in a timely manner.

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6. LESSONS LEARNT IN THE IMPLEMENTATION OF THE BOMA MODEL There have been a number of key lessons learnt through implementation of the BOMA Model. These lessons are relevant both for future activity in Magadi and for agencies considering replication of the BOMA model for service delivery in other communities. (i)

(ii)

(iii) (iv)

(v)

(vi) (vii)

(vii)

Well trained and supervised CHWs are critical in social mobilization and creating demanding for MNCH services in the communities. In Magadi, CHWs have played a major role in health education and promoting utilisation of MNCH in health facilities, by addressing socio-cultural barriers that they are conversant with. As the community creates demand for MNCH services, strengthening on the supply side is critical. Positive health-seeking behaviour in the community is undermined when individuals attending health facilities find the centre understaffed or under resourced. Inadequate HRH is the biggest challenge affecting the health care delivery system in Magadi and Kenya and must be addressed urgently. Without incentives and compensation, retention and motivation amongst volunteer CHWs will continue to impact Level One service delivery in Magadi. Reorienting the role of TBAs and actively incorporating them into service delivery has increased ANC visits and ensured greater community acceptance of MNCH services. The Community Strategy should incorporate TBAs and other informal traditional health workers into formal policy and implementation guidelines to strengthen communities' capacity to take greater control of their health. A strong behaviour change communications (BCC) component would serve to strengthen the BOMA model, particularly if it is designed to accommodate low literacy levels in Magadi. For that reason, AMREF is in the process of finalising a BBC component for the Magadi project. Strengthening advocacy at all levels, from women and children, to Boma heads and local administration, through to health facilities and the DHMT is critical to improving health in Magadi district. Integrating the BOMA model with interventions that target communityidentified priorities will enhance engagement on health. For example, waterrelated interventions in Magadi would increase community receptiveness to the MNCH project as water is an ongoing and pressing community need. While skilled attendant deliveries increased (14.8% to 23.8%), a number of barriers exist; lack of public transport (28%), limited appreciation for skilled delivery (21.6%), cost (19%), facilities not open at night and weekends (9.5%). Future interventions should aim to address these

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7. POTENTIAL FOR REPLICATION 7.1.

Potential areas for replicating the BOMA Model

While the BOMA model as described above is most relevant to agencies delivering the Community Strategy and MNCH services to Maasai communities, there is potential for both replication and adaptation in different nomadic pastoralist communities and contexts. The BOMA model should be consider by agencies working in one or more of the following areas: ! Implementing the Community Strategy in nomadic pastoralist settings ! Delivering Maternal, Newborn and Child Health (MNCH) services in nomadic pastoralist communities ! Serving similar regions and communities: Samburu, Narok, Maasai Mara, Loitoktok, Turkana and Tanzania ! Serving other semi-nomadic pastoralist communities (e.g. the Afar in Ethiopia, Bedouins in Libya and nomadic communities in countries such as Mongolia and Nepal) AMREF has already adapted the BOMA model in the Samburu Maternal Newborn Child Health Project, in Samburu County in the Rift Valley. The project commenced in 2011 and is showing promising results.

7.2.

Steps in replicating the BOMA model

1. Community entry. Identify community gate keepers such as provincial administration including the chiefs and Asistant Chiefs, village elders, Boma heads, DHMT and introduce the project to them for community buy-in. 2. Identify other potential partners in the community such as NGOs, CBOs, provincial administration, private sector etc for support, collaboration and synergy 3. Work with the DHMT ,provincial administration and village elders to identify existing CUs to strengthen or new CUs to establish with a focus on Bomas. A Boma should be covered by one CHW and not split among many CHWs. The CHW must first be assigned the Boma that he/she resides and the neighbouring ones. 4. Identify and create rapport with Boma heads where community units will be established/strengthened. 5. Conduct community sensitisation on establishment of the community unit and selection of CHWs and CHC 6. Facilitate the DHMT to train CHEWs on the community strategy 7. Facilitate DHMTs and CHEWs to train CHC and CHWs on the community strategy. Continuous trainings for CHWs on thematic topics such as reproductive health should continue through the project 8. Provide reporting tools, identification materials and other required supplies to CHWs based on the community strategy operation guidelines 9. Establish CBHMIS and train CHEWs, CHC and CHWs on the same 10. Facilitate CHEWs and CHC to conduct dialogue and actions days

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11. In collaboration with the DHMT, CHC and CHWs, Identify and train TBAs on redefined roles as safe motherhood promoters 12. Train health facility staff on obstetric care, customer care and related topics to improve quality and response to increased demand 13. Renovate and equip health facilities where possible to improve quality of services and to enable them respond effectively to increased demand for services 14. Provide support supervision to DHMTs, CHEWs, CHC and CHWs 15. Facilitate regular stakeholders' fora to share progress, lessons learnt and best practices. Different stakeholders should volunteer to support the fora on a rotational basis.

7.3.

Cost Elements of the Model

The model is built on the community strategy and may attract costs related to establishing and maintaining a functional community unit. Other related costs include trainings and outreaches as enumerated below. These costs can however be shared in a partnership model. ! Conducting formative assessments ! Establishing community units ! Training CHWs, CHEWs, CHC and TBAs ! Training health workers ! Interventions in the Boma ! Support supervision ! Transport for outreaches ! Developing IEC materials

7.4.

Sustainability

! The Boma model has invested in strategic partnerships with the community and

private sector such as TATA and KWS who will be in the community longer and will continue to support the model after AMREF. Secondly, the model has brought all stakeholders on board through divisional stakeholders' fora where stakeholders meet to discuss progress. The fora are supported by all partners in a rotational manner, making them sustainable. ! The Boma model has strengthened organisational systems within community units by training them on leadership and governance, financial management among others. The CUs have been registered as community based organisations, which makes them capable of fundraising to continue their activities. ! The Boma model has further strengthened coordination by the decentralised structures of the ministry to enable them continue to provide technical support to CHWs ! Capacity building: The Bomas will continue to implement health promotion activities due to the skills and knowledge gained.

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7.5.

Risks and Assumptions

Risk

Implication

Mitigation

Community leaders and Boma heads not receptive to the model's health interventions.

If time is not taken to build rapport, gain trust and ensure community buy-in, there is the risk that the model will only reinforce power held by community gatekeepers, at the sake of the most marginalised.

Boma heads need to be actively and continually engaged to gain access to the target beneficiaries, i.e. women and children, and to ensure positive, wellinformed health decisions are made on their behalf. Engage the community with respect, connect with deep-rooted community structures to ensure sustainability and encourage ongoing grass root involvement of gatekeepers

Poor quality health system Negative experiences such as absent infrastructure. health staff during deliveries and poor road network can be a disincentive to positive health-seeking behaviour and -Distance undermine the work of CHWs -Inadequate health staff Magadi only had one 24 hour facility, a -Drug stock outs factor that contributed to a higher proportion of home deliveries

Train health workers and adequately staff health facilities Improve facilities to promote 24 hour deliveries including weekends Have strategies that strengthen the supply side to handle increased demand

Gender imbalance in the formal health workforce

In Maasai culture, pregnant women have a strong preference for female health workers during delivery. CHWs in the region tend to be more males than females

Natural Disasters

Adverse effects of drought characterized Sensitise the community n emergency by acute water, food and pasture preparedness shortage can result in mass migrations of communities from static health facilities. This could result in low hospital deliveries, ANC and Immunization and defaulters.

High attrition rates among CHWs

Address gender balance in health facilities and recruitment of CHWs Young and/or male CHWs partner with other older and/or female CHWs when dealing with sensitive situations. Promote girl child education

Mainstream sustainability for CHWs in the initiation of community units

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8. BENEFICIARY PERSPECTIVES ON THE BOMA MODEL A Traditional Birth Attendant (TBA) takes on new role to promote uptake of MNCH services TBAs, like Alice, are a respected institution in the Maasai culture and their word on reproductive health issues is highly regarded by the community. However, over reliance on unskilled deliveries by TBAs has resulted in high maternal and infant mortality in the region. “Before AMREF started to work with us, we had a lot of cases of malaria and many deaths among pregnant women and children in a day. Many women preferred to be delivered by TBAs instead of going to the clinic. Some say it is because they do not like the delivery position at the clinic/hospital or to be delivered by male nurses. AMREF has taught us a lot. They have opened our eyes. TBAs like myself have been trained on several issues such as identifying danger signs during pregnancy, danger signs in newborns and young children, care of pregnant mothers including nutrition, preparation of birth, safety and precaution measures and referrals. Now I don't deliver women at home. Even when they come, I tell them and accompany them to go to the clinic”. She says all her children and grandchildren were delivered in a health facility and have also been fully immunised. Because of her engagement with the community, Alice was selected to be a member of the Community Health Committee (CHC) in her community unit. “As a CHC, I often accompany the CHWs as they go to visit beneficiaries in the Boma.” TBAs are also custodians of culture especially those related to FGM and food taboos. As such, they controlled what and how much pregnant women eat, in the fear of having bigger babies and complications during delivery. “Pregnant women were advised to eat only once a day”. This resulted into many cases of anaemia in pregnancy. “But now many of the women are encouraged to attend at least four ANC visits where they are also given proper guidance on nutrition”. According to Alice who has also been trained on advocacy, men are gradually changing their attitudes towards women because of the knowledge they have received. “Now we have men who escort their pregnant wives to the clinic. They also save money and buy clothes for the baby”. Through integration with the AMREF Unite for Body Rights Project, anti FGM advocates like Alice have sensitised the community to embrace alternative rites of passage. “Men are also now engaged in fighting FGM. Most of them did not even know where their daughters are cut during FGM and were shocked when we showed them. Girls who have gone through the alternative rites of passage were given certificates and they influence other girls to shun the FGM. AMREF, through the Boma model, has opened our eyes and we are sad that they are leaving. They even took my child to school and now she is in Form One”. Alice's story represents that of many TBAs who have taken up new roles to promote uptake of MNCH services within the community and improve the lives of Maasai women and children.

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Applause from the Senior Chief The provincial administration's authority is highly regarded within the Maasai culture since they are considered to represent the government. Senior Chief Joel Sayianka, applauds the Boma model saying it has brought different players on board and is a pointer to real change. “The Boma model brings everybody on board. Assistant Chiefs are now more involved. Elders who were not able to sit and discuss health issues now do so. Morans now talk about sexual and reproductive health”. He points out some cultural beliefs and practices that hindered uptake of MNCH services among Maasai women in Magadi. “It was a taboo for a woman to disclose early pregnancy”. They were therefore not able to initiate ANC visits early until the pregnancy was visible. “Pregnant women had poor nutrition, for instance fresh milk was believed to make a child big. In the Boma model, people discuss and come up with solutions, which enhance ownership. Community leaders know about the model and many people have heard about it. As a result, people now take their children to the clinic; uptake of family planning is improving and women can now decide when to conceive as well as discuss reproductive health issues with their spouses; men can now talk about FGM”. Perspective of a Community Health Worker and Community Health Extension Worker Paul Sayianka has been involved in the implementation of the Boma model from its inception in 2007. He is the Divisional Public Health Officer and was among the first CHEWs tobe trained by the MNCH project. “The CommunityStrategy was launched in 2007 by the Ministry of Health to deliver LEVEL ONE services. We workhand in hand with AMREF to implement the strategy in Magadi. AMREF facilitates and the DHMT implements. We have initiated 8 community units, trained 22 chiefs to assist CHWs in educating the community, trained CHWs and CHCs. The CHWs have been issued with bicycles for referrals, and IECs materials including T-shirts, aprons, kikois, caps and job aids. They hold community dialogue and action days. Each Boma is assigned a CHW and a CHC. The DHMTs and CHEWs conduct supportive supervision to CHWs. As a result, health information and awareness has

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increased; there is greater community participation and involvement; malaria cases have gone down due to use of LLITNs; acute respiratory tractinfections have gone down due to modified chimneys; collaboration with TCML and KWS to supply water through the water tanker has reduced man hours spent looking for water and reduced water bone diseases. Waiting Bomas have been put up to encourage skilled attendant deliveries, and men also refer their wives to the facility”. Paul's account is corroborated by that of Peter Mukare - a CHW. “The Boma model has contributed to decreased immunisation defaulters. Mothers have embraced exclusive breast feeding. Diarrhoeal cases have reduced because people treat water and use leaky tins and soap; eye illnesses have also reduced due to separation of the livestock from humans houses; men are accompanying their wives to the facility and allowing family planning. He says that part of the success of the model has been due to cooperation between the community, CHWs, Ministry of Health and stakeholders”. Being a male CHW, Mukare sometimes experiences challenges getting information from young women when he suspects that they are pregnant since they do not easily disclose. “In such cases, I use husbands to get information from young mothers”.

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Additional Quotes from Project Beneficiaries “When Maasai children were born, herbs were prepared and mixed with milk and some water as form of treatment or immunization for children. The project has educated parents on the importance of child immunization. More women are delivering in hospitals and also seeking baby well clinic services. Generally people in this area are utilizing health facilities more when ill and practicing preventive health, like water treatment using aqua tabs and hand washing using leaves and ashes.” Observed the Assistant Chief of Pakase “This project (Josephine's) should continue! As a women leader who has attended two trainings on mother and child health, I believe the CHW's worked with TBA's strengthen referral from level 1 to higher levels 2 or 3. The facilities have benefitted immensely from the equipment supported such as delivery kits, LLITNs, delivery beds, solar panels etc provided by the project. The support received to date shall go a long way in serving the locals and in the delivery of maternal and child health services”. – Woman key informant in Entasopia

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REFERENCES AMREF, 2007, Baseline assessment for the Manyatta Based delivery for MCH, Magadi Division, Kajiado district, AMREF, Nairobi AMREF, 2009, Mid-Term Evaluation Report; Magadi Integrated Health Project; Maternal, New Born and Child health “Boma Delivery Model”, AMREF, Nairobi AMREF, 2010, End Term Evaluation of The Maternal Newborn and Child Health (Mnch) Boma Delivery Model- Magadi Division, AMREF, Nairobi Dahlberg LL, Krug EG. Violence-a global public health problem. In: Krug E, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds. World Report on Violence and Health. Geneva, Switzerland: World Health Organization; 2002:1–56. MoH, 2006, Taking the Kenya Essential Package for Health to the Community: A stategy for the delivery of LEVEL ONE SERVICES, MoH, Nairobi KNBS, 2009, Kenya Demographic and Health Survey, Nairobi, Kenya

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