CHAPTER is need for efficient and effective

Decision Making

CHAPTER ONE: BACKGROUND INFORMATIONIntroductionZimbabwe is one of the countries with high HIV burden.

According to the recently published ZIMPHIA report, Prevalence of HIV among adults aged 15 to 64 in Zimbabwe is 14.1%: 12.0% among males and 16.

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0% among females. This corresponds to approximately 1.2 million persons aged 15 to 64 living with HIV in Zimbabwe (ZIMPHIA, 2015-16). On another note, Zimbabwe has committed to having 90% of all persons diagnosed receiving ART, and 90% of all persons receiving ART virally suppressed by 2020. ZIMPHIA shows that among all HIV-positive persons aged 15 to 64 years, 72.9% knew they were HIV positive, which is still somewhat below 90% target for awareness of HIV status.

Of those who knew their HIV status, 86.8% were on ART, and of those who reported being on ART, 86.5% were virally suppressed both very close to the 90% targets (ZIMPHIA, 2015-16).HIV Care and Treatment service has been at the epicentre of fighting the pandemic ever since exponential increase of HIV related mortality.

Skovdal et al, (2011). With the ever increasing number of people on treatment, approximately 1.2 million (ZIMPHIA, 2016), there is need for efficient and effective service delivery as far as art is concerned.

ministry of health has adopted different strategies in its hope of curbing the pandemic. Zimbabwe like most countries globally has adopted a differentiated care model which entails decentralization of ART services. This model has its own strengths and weaknesses as highlighted by most scholars. This paper will mainly focus in examining the role of community ART service delivery in form of community ART refill groups in addressing a plethora of challenges faced by PLHIV and communities at large.

In its quest to examine the role of the CARGs as a community ART initiative, this research will also explore strengths and weaknesses of other models of ART delivery currently being implemented.Background of the studyAt the end of 2013, 12.9 million people were receiving antiretroviral therapy (ART) globally; that same year, the percentage of people with HIV receiving ART rose to37% (up from 10% in 2006) (MSF2016).

Whereas this marks a substantial improvement, it means that of the 35 million people living with HIV at the end of 2013, 22 million people-3 in 5 people living with HIV were not accessing ART (UNAIDS,2014). At the same period, about 700 00 -800 000 people in Zimbabwe were HIV Positive 55% of them were on ART and facilities providing ART being less than 440 (UNAIDS, 2014). By 2016, the total number of clients on ART was now 975 667 compromising 66 159 children and 908 508 adults (UNAID, 2017).

However, there has been a significant increase in the number of sites providing ART from 530 in 2010 to 1566 in 2016. (MOHCC, 2016). This however translated in an increase in overall ART coverage which by December 2016 was now at 68.3% from 55%, with 83% ART coverage among children (0-14) while adult ART coverage was at 66%, based on the total number of people living with HIV in line with the ”Treat All” approach (UNAID, 2017).

Antiretroviral therapy (ART) provision to people living with HIV (PLHIV) remains a key priority for Zimbabwe’s Ministry of Health (MOHCC, 2013). According to the recent ZIMPHIA 2016 report, 74% of PLHIV (15 to-64 years) are aware of their HIV status and 87% of them on treatment and 86% virally suppressed. Although the country has achieved high treatment coverage, issues of quality and retention in care remain a challenge, according to the FHI360, 2015) Zimbabwe HIV Care and Treatment (ZHCT)program), of those testing HIV positive, 84.2% of PLHIV were enrolled in care and 70.4% were initiated on HIV treatment (97.2% and 78.0% in Manicaland; 74.2% and 64.

5% in Midlands). These data show that there are still gaps in HIV care and treatment coverage in supported facilities, particularly in Midlands where the gaps is larger, indicating a need for enhanced strategies to improve service linkage across all supported sites in order to achieve UNAIDS’ second 90-90-90 target, 90% ART coverage among PLHIV. This however calls for integrated efforts in closing the gap.The gap in terms of treatment coverage might be as a result of compounding factors such as attitude of health facility staff.

Campell et al, 2011) alluded to the fact that patients not properly adhering to their medicines are labelled as good patients hence listened to when compared to defaulters. They again reinforced the point that this will rather keep defaulters outside of the facility rather than inviting them in. Campell et al 2011 also highlighted that facility based ART service provision exposed PLHIV to more stigma rather than reducing it. They in their conclusions highlighted that community ART groups will address this key challenge and as well serve as platform to discuss for PLHIV.Since adoption of the primary health care policy in 1980, Zimbabwe ministry of health regardless of support from civil societies, faced a plethora of challenges in terms of quality service delivery.

However, communities have raised issues of health workers shortages and attitudes, availability of medicines and equipment, patient transport, impatient facilities such as beds, food and ablution facilities, amongst other things as key challenges to the health facility level service service system. Zimbabwe MOHCC adopted a differentiated care model by turn of 2011 were ART services were to be offered at lower level facilities (MOHCC, 2014). This was a positive move in decongesting provincial and district hospitals but however since then human resources to support such move has been a major crisis.

World Health organization densities per 1000 populations were 1.34 and 0.083 midwives/nurses and physicians. Hirschhorn et al 2006 asserts that for efficient delivery of ART services at each facility, there is need for 1-2 physicians and 2-7 nurses who will be doing all duties from outpatient’s services, anti-natal care to ART services. This has been one of the reason why there are high rates of defaulting. Nkatha et al (2016), states that one of the key strategies to deal with the human resource shortage is task shifting to communities.The national goal for MOHCC is to achieve HIV epidemic control by decreasing HIV related illnesses and deaths, and decreasing new HIV infections. However, all this will only be achieved through consistent and constant supply of ART services coupled with adherence.

Of late adherence and consistent supply of ART services has been ART services has been a challenge largely because of both individual and facility factors. Continued decentralization of the delivery of HIV care and treatment services has helped increase access to ART at decreases cost to the client. The MOHCC acknowledges the need to minimize the client related costs and opportunity costs incurred by ART clients because of frequent visits to facilities and extended waiting time within the facilities as ART client volumes increase.Even if coverage is increased, the health of people living with HIV and AIDS can only be achieved when adherence to antiretroviral treatment is strictly maintained (Machitinger and Bangsberg, 2005). Adherence to antiretroviral treatment reduces mortality in HIV positive people through viral load suppression; conversely, no adherence is highly correlated with risk of progression to AIDS, demonstrating that adequate adherence is vital to promoting positive treatment outcomes (Bangsberg et al…2001; Gifford etal.

..200).

Research has it that there is a likelihood of drop outs if drug refills are done at a distant facility (Gregson et al…). Research purports that those who are 80% adherent to antiretroviral treatment have nearly doubled doubled viral reduction compared to individuals with less than 80% adherence rates (Steele ; Grauer, 2003). Studies indicate that adherence to antiretroviral treatment averages 70%. Some antiretroviral medications, however, require;95% adherence to have their full intended and sustained effect (Machtinger ; Bangsberg, 2005).

Men are generally less likely to join groups where HIV and AIDS are discussed.Community level services relate to those services provided in the community and at sub district and even at village or household level as part of community participation in co- production of needed services closer to the families or households. Community ART groups are one great example of community level provision.Community based ART groups are a community initiated strategy to reduce adherence barriers related to difficult access to care (fhi360 2014). CARGs have been commonly implemented with hard to reach groups and in rural settings. They rely on preexisting social networks such as support groups. In urban settings, it is recommended that CARGs be promoted for groups of family members and workmates. A CARG is a self-forming group and must have a minimum of two clients (referred to as ”treatment buddies”) and a maximum of six clients.

The efficiency (time and monetary) of this model is through cost sharing achieved by rotation of clients (group representatives) in visiting the facility to collect ART treatment for group members.To join group, patients have to be stable on ART (being at least six months on a first line regimen with CD4 above 200/mm# and, MOHCC 2015 and FHI360 2015). Each group elects a group leader among its members, who coordinates the group activities and functions as a spokesperson of the group. The group will coordinate periodically on who will go and collect medication for all the group members. The group will also serve as a platform and social discussions on issues affecting people living with HIV.Mining communities have been identified as among the highest risk groups for HIV infection in countries with high overall rates of HIV and AIDS prevalence (MOHCC 2014). Vulnerability to HIV and AIDS stems from, the time panners spend away from home, their access to cash income, their demographic profile, the ready availability of commercial sex in gold panning fields and the sub cultures of risk taking and hyper masculinity in gold panners.

It also can be noted that adherence for people in such communities is extremely poor as well since they spend most of the time away from their homes, no time to visit health facilities to have refills. However, Community ART refill Groups in such communities have been viewed as an immediate solution by retaining more clients in care.It however is against this background that the author found it useful to conduct this research and unpack the GARG model, examine its role in addressing plethora of challenges faced by PLHIV in Kwekwe as well as providing evidence for policy formulation and decision making.

Research ProblemSince advent of antiretroviral therapy (ART), it has proved to be a key element in curbing the spread of HIV. When adequately adhered to, ART is known to halt the progression of the virus and allow the HIV infected person to live a longer, more productive life. However, retention to care for ART patients collecting medicines at facilities individually has been on the decline in the past five years and some of the reasons for the decline are attributed to the deteriorating patient client relationship (WHO 2014).

Looking at the continuum of care framework, quite a number of patients drops out at every stage of the HIV Care and treatment model (MOHCC 2014). Ministry of health with support from non-governmental organizations such as FHI360, MSF has resorted to adopting the differentiated care model with the aim of strengthening the community systems. This has been viewed as a solution to a myriad of problems being faced by health facility in line with providing ART services for people living with HIV. Implementation of various community initiatives including the CARGS have been going on for more than 3 years now and effectiveness of such initiatives has not been examined widely. Therefore, there is need for examining the impact of the community ART initiatives being implemented in Kwekwe district with the thrust of wanting to articulate on lessons learnt.This research will however focus on examining the role of the CARGs in improving adherence and retention too care f of PLHIV. The research will start by understanding the role of CARGS WITH THE AIM of providing lessons learnt from areas already having these groups.

Since Alternative care models implemented in resource limited settings have been taken to scale this research will also work in providing sufficient evidence for scale up.Significant of the studyPublic health authorities often seek evidence that new models of care have proved to be feasible, acceptable, cost efficient and effective outside of research settings, yet such ”real-life” evaluations of programmes that have achieved partial or full scale are rare (Nkatha et al 2016). The study will add value to the body of data that will inform public health policy and programming by providing promising practices as well as lessons learnt from community ART initiatives in Kwekwe district. The findings of the study will help in the health quality improvement especially within the concept of differentiated care model.

The knowledge gained in this study will help in making recommendations regarding development of appropriate health strategies to empower clients, health personnel and policy makers about the importance of community ART initiatives such as the CARGs to improve retention into care and treatment. It will also help the health planners in reviewing the ART guideline to make the necessary changes regarding community antiretroviral therapy from the individual, community to national levels.Objectives of the studyTo describe the Community ART Refill Group and its goalTo examine the role of Community ART Refill Groups in addressing challenges faced by PLHIV in KwekweTo provide lessons learnt from implementation of Community ART Refill Model in KwekweDelimitation of the StudyKwekwe district is located in Midlands with a total estimated population of 289 687, 49% males, 51% females, 36.7% urban population and 41.1% aged between 0-14years (ZIMSTAT, 2012).

Its home to the second largest urban community in the Midlands Province after Gweru. The district capital is located approximately 220 kilometres, by road, South West of Harare, the capital of Zimbabwe and he largest city in that country. Kwekwe lies on the main road, Highway A-5, between Harare and Bulawayo. Zimbabwe’s second largest city, located approximately 230 kilometres, further South West of Kwekwe.

The city of Kwekwe is sustained by both formal and informal mining activities. As industry collapsed owing to a decade long political crisis, thousands of workers formerly employed by disintegrating mining companies and downstream industries turned to artisanal gold panning for survival (Ejatlas 2017). Economically, like most of the districts in the Midlands, Kwekwe is a mining town with a lot of illegal gold panning activity, iron mining and smelting industries. It consists of both Shona and Ndebele speaking groups both in urban and rural. This district was selected for its uniqueness in terms of socio economic factors, being driven by gold panning activities.

Evidence has shown that gold panning (24% which is higher than urban 22% and rural 21%) background has a large impact in terms of fuelling the spread of HIV, largely because of their risky sexual behaviours (MOHCC 2015).Limitations of the ResearchThe findings will be limited to the selected health facilities and their catchment areas in one programmatic district and cannot be generalized to other districts in Zimbabwe.Ethical considerationsThe study will be done in line with the minimum required standards as guided by Medical Research Council as well as the Great Zimbabwe University ethical review board.Informed consent is a mechanism for ensuring that people apprehend what it means to partake in a particular research study so they can choose in a mindful, thoughtful way whether they want to participate. Informed consent is one of the most vital tools for ensuring respect for persons during research (fhi360 2001).

Those not agreeing will not be coerced or have their relationship with any institution or person affected. Participants will be required to sign a consent form before participating and be ensured that there is no harm in participating in the research.Confidentiality: Data collection will be kept in confidence and decoded to minimize chances of identifying the source at analysing level.

Opt in Opt out- participants will not be coerced to continue with the study even if the few like discontinuing. The research study will adopt an opt in opt out.Definition of Key TermsAdherence-It is an extent to which clients behaviour coincides with the prescribed health care regimen as agreed upon through a shared decision making process between the client and a health care providerRetention into care- defined as the proportion of participants remaining in care 12 months after enrolment by intention to treatCARGS- These are self-formed groups of stable patients on ART from a community in the same geographic location.CHAPTER TWO: LITERATURE REVIEWIntroductionWeaknesses of Health facility centred ART provisionTraditional models (facility centred) has led to overcrowding and long waiting times at clinics, with many people waiting solely to pick up drug refills. This high workload tend to overtax health workers and, due to weak structure, they also face challenges to follow-up according to the guidelines in which they have been trained Apollo et al 2017. These challenges have led to a varied picture of effectiveness among HIV care and treatment systems. However, on the other hand, individuals who have been linked to care and treatment and retained on ART achieve high rates of viral suppression (Apollo et al 2017).

However, studies report substantial loss to follow up across all steps of the care cascade.Most pregnant women in Zimbabwe and most other Sub Saharan countries are expected to get an HIV test during anti natal visit. With the advent of the ”treat all” approach globally, there are a number of key lessons to be learned from the prevention of mother to child (PMTCT) OPTION b+ FOR PREGNANT WOMAN. Myer et al 2017 suggest that there are poor rates of retention among women initiated on ART during pregnancy. Myer et al 2017, also postulates that the six month post-partum outcomes of women who are initiated during pregnancy are reported after their self-selection into a healthcare worker managed group (community adherence clubs) or referral to their local primary care clinic.

While their study provided vital evidence of poor retention, the study could not assess if women referred to but not retained in adherence clubs where retained on the other ART services, it however provided evidence that PLHIV may benefit from different service delivery models throughout their life time.In Malawi, the PMTCT Uptake and Retention (PURE) study showed that mothers living with HIV who received expert peer support were significantly more likely to be retained in care at 24 months post initiation of ART. This was true regardless if the support was provided at facilities or in the community (approximately 80%, 83% vs. 66%). The positive effect of peer support was primarily seen in the period between 12 and 24 months after ART initiation (McGuire etal, 2010). Rates of attrition were between 30% and 40% less among women receiving expert peer support. The number of women coming back into care after a period of defaulting was also higher in settings s throughout their life time.In Malawi, the PMTCT Uptake and Retention (PURE) study showed that mothers living with HIV who received expert peer support were significantly more likely to be retained in care at 24 months post initiation of ART.

This was true regardless if the support was provided at facilities or in the community (approximately 80%, 83% vs. 66%). The positive effect of peer support was primarily seen in the period between 12 and 24 months after ART initiation (McGuire etal, 2010). Rates of attrition were between 30% and 40% less among women receiving expert peer support.

The number of women coming back into care after a period of defaulting was also higher in settings where there was community based expert peer support compared with either standard of care or facility based expert peer support (McGuire et al 2010). This study however supported the positive effect of peer support in retaining in care and uptake of health services by mothers living positively.Staff AttitudeIn one study conducted in the United States to determine if there was a correlation between adult HIV positive patients, satisfaction with their physicians, and ART adherence. Results showed a seeming association between the perceived relationship and levels of adherence- good patient provider relationships strengthened adherence and poor relationships hurt adherence (Robert W et al 2013)).

In a study in Nigeria found that a significant number of health professionals showed discriminatory attitudes and engaged in unethical behaviour towards patients with HIV and AIDS, such attitudes serve as a barrier for delivery of health services to HIV positive (Reis et al, 2005).Campell et al (2011) alluded to the act that patients not properly adhering to their medicines are labelled as good patients hence listened to when compared to defaulters. They again reinforced the point that this will rather keep defaulters outside of the facility rather than inviting them in. Campell et al 20111 also highlighted that the facility based ART SERVICE PROVISION exposed PLHIV to more stigma rather than reducing it.Decentralized Community ART Centred InitiativesFor purposes of this research, ART decentralized is defined as provision of care and treatment not only at a primarily care facility but also at community level either through village health workers or other cadres. Despite the introduction of ART and its rapid scale up in each country, staffing levels were not increased to cater for these new and specialised services. Nkatha et al, 2016 a 2010 study of 17 countries showed that a third of patients on ARVs dropped out of treatment within two to three years.

Patients accessing care through community models, however have better treatment adherence than those who choose to stay in conventional care. In Khayelista, South Africa, for example, 97% of patients in adherence clubs remained in treatment after 40 months, compared to 85% of their peers. Among stable patients on ARVs, over 90% of patients in the Tete Province of Mozambique were still taking their medication after four years in CAGs. In the DRC, after two years, 91% of PODI members were still undergoing treatment.A number of different approaches have decentralised care to the community or to the home. These models minimise the number of required clinic visits by utilising community health workers or peers to deliver care or treatment either at home or at community meeting point.

The spacing of appointments as well as the use of lay workers to dispense drugs means that already overworked nurses can dedicate their time to other things. With the CAGs there is a 59% reduction in ARV refill visits and a 43% reduction in overall clinic visits (data from 2013). This equates to a large reduction in health staff workload (MSF 2017). The community health workers ranged in education and training, and the qualifications and pay for community health care workers varied throughout the models. Overburdened health systems, lack of patient focused services, resource limitations and mixed quality of care have led to efforts to modify the delivery of HIV care in a framework that addresses the causes of poor retention. Task shifting is one of most common approaches.

A number of studies evaluated the impact of a decentralised, facility based model in which stable individuals were down referred from HIV clinic (where care was generally provided by a doctor or clinical officer) to a primary care health centre (where the care was generally provided by a nurse). Among the 39 000 individuals included in a meta-analysis of this approach, loss to follow up per 100 patient years 7.4 (95% CI 6.0-9.3) in the primary care centre group compared to 13.4 in the HIV clinic group and mortality per 100 patient years was 2.8 (95% CI 1.1-7.

3) in the primary care centre group compared to 8.4 in the HIV clinic group.In the Western Cape of South Africa, MSF, driven by the need to provide better patient centred care and to decongest over crowded HIV clinics, developed a model in which care, including ART drugs refills, is provided either at the clinic or in community venues in a group setting. These groups, referred to as ART adherence clubs, are facilitated by a community healthcare worker. Forty month retention in the clubs in Khayelista is 97% (club) vs 83% (clinic) with a 67% reduction in virological rebound among those in clubs compared to clinics. This model has been adopted by Metro District Health Services from initial MSF project in Khayelista to include 27 800 people (1/4 of total individuals in care by end of June 2014) in the Cape Town Metropolitan region. A model that is effective in urban South Africa, where resources and infrastructure are generally better, may not be reproducible with similar results in more resource limited Tsondai et al 2017.

Assessed outcomes of clients in healthcare worker managed adherence clubs in the Western Cape of South Africa, with a random sample of 10% of clients from non-research supported sites with high rates of retention and viral suppression, this evidence confirms that good outcomes among patients differentiated into a healthcare worker managed groups are not limited to pilot projects.In Mozambique, MSF has collaborated with the Health Ministry to implement and scale Community ART Groups (CAGs) throughout the country CAGs are group of six individuals from which one rotating person in the group acts as the monthly ART collector for all members. Thus, each CAG member visits the clinic every 6 months. Eligible people must be stable on ART for >6 moths and a CD4 count >200. Retention at 12, 24, 36 and 48 months, respectively has been 97.7%, 96%, 93.

3% and 91.8%, and a mortality has been 2.1 per 100 people’s years.Typically, majority of studies reported viral load suppression of people in adherence clubs and programs (programmes (Sarna et al…2008; Taiwo et al…2010, Van loggerenberg et al.

. 2014), retention to care (Visnergarwala et al..,2006), high adherence levels (Williams et al..,2006, Pearson et al.., 2007, Sarna etal.

., 2008) and increased CD4 counts (Coetzee et al..,2004; Kabore et al.., 2010).

These studies demonstrate that behavioural and cognitive learning processes are vital in achieving the desired AT health outcomes. Chenneling specific interventions has proved vital in maintaining optimal levels of adherence (Tuldra et al., 2000; Amico et al., 2005)This home based HIV care strategy is as effective as is a clinic based strategy, and therefore could enable improved and equitable access to HIV treatment, especially in areas with poor infrastructure and access to clinic care (Jaffar et al).Sometimes accessing ART might be affected by long existing patriachical systems. Hegemonic notions of masculinity can interfere with women’s adherence to ART.

It is important that those concerned with promoting effective treatment services recognise the gender and household dynamics that may prevent some women from successfully adhering to ART, and explore ways to work with both women and men to identify couple based strategies to increase adherence to ART (Skovdal et al) men are generally less likely to join groups where AIDS is discussed.Community delivered ART requires simple and robust data collection. Unique identifiers, referral tools and data management systems are needed.

However, an extensive literature review has demonstrated that to date little systematic scientific research has been performed on the contributory contributory role of these community support and expert patient structures in HIV and AIDS treatment programmes and the health systems at large in resource limited countries (Wouters et al 2009).Comparable to other country findings, high rates of lost to follow up (LTFU) occur among pre-ART clients in Uganda (Muhamadi et al, 2010, Lubega et al, 2010, Scheibe et al, 2012). Lack of incentives for PLHIV and health care workers, long waiting times at health clinics, and inadequate counselling were associated with late ART initiation (Muhamadi et al 2010) and a high dropout rate of pre ART CARE (Lubega et al 2010). Additionally, high attrition rates in pre ART care in Eastern Uganda were also related to competition with traditional healers, transport costs and gender inequality, however quality counselling was motivation to return to care (Lubega et al 2010, Muhamadi et al., 2011). This study also shows equivalent challenges faced by most people living with HIV in Zimbabwe.Observational research in Zambia has shown that 2 and 3 monthly visit intervals were associated with decreased loss to follow up (LTFU) and decreased visit lateness compared to patients who attended monthly (Lubega et al.,2010).

A recent systematic review found that reduced frequency of clinic visits and medication pick up for ART patients might lead to improvements in program retention and patient outcomes (Tsondai et al., 2017).Theoretical FrameworkThe successes of ART adherence programmes can also be explained by theories of human behaviours. Bandura (1991) noted that a theory of human behaviour explains how human and cognitive behaviour is acquired along with how individuals motivate and regulate their behaviour in everyday everyday life. Social modelling has the power to change human behaviour as it exhibit strong motivational effects (Bandura, 1991).

The author suggests that good behaviour acts as social prompts that initiate, directs and aids modelled behaviour. In essence, the achievement of personal and programmatic goals I facilitated by interdependence efforts in which knowledge, skills and resources poling act in concert to shape personal wellbeing (Bandura, 1991).One of the prominent critics of programme theory, Donaldson (2007) suggests that many health behaviour programmes are informed by a variety of multiple component interventions. These programmes are hypothesised to have multiple mediator and moderator variables. The recent model by Fisher et al..

.(2006) , the information motivation behavioural skills Model (IMB Model) in cooperated constructs from earlier models or theories such as the health belief model, theory of reasoned action and theory of planned behaviour to explain ART adherence. Fisher et al (2006) argues that optimal ART adherence is linked to (1) the extent to which an individual retains information, (2) the individual’s motivation to act on the information, and (30 the individual’s ability to adopt positive behavioural skills.Firstly ART adherence related information comprises giving out the exact information on specific schedules, ART dosing and optimal adherence, and side effects associated with the regimen (Fisher et al.

, 2006). Secondly, an individual’s motivation to adhere to treatment may be influenced by attitudes towards adherence, beliefs about health outcomes and evaluations of these outcomes (Amico e tal., 2005). In essence, a highly motivated individual may be inclined to adhere to ART treatment and vice versa. Moreover, social motivation to adhere depends on one’s perceptions regarding ART adherence and social support are associated worth greater ART adherence. Lastly, behavioural skills are thought to be critical in ensuring ART adherence include observing and strictly following prescribed regimens ability to minimize and cope with adverse effects, integration of ART into social structures and maintaining optimal adherence.

However, Fisher et al (2006) acknowledge that information and motivation may have direct effects on adherence behaviour in situations where complicated or new behavioural skills do not affect adherence. Nevertheless, in complex and challenging ART schedules, the effect of information and motivation on adherence behaviour is mediated by adherence related behavioural skills (Fisher et al., 2006).

Moreover, an individual’s characteristics and social context may moderate the cause effect relationship. The model also stresses that ART adherence is directly connected with health outcomes which are believed to influence one’s future ART adherence through a feedback loop (Fisher et al., 2006). Through the IBM model, Fisher et al (2006) demonstrated that health behaviour programmes targeted programmes targeted at promoting ART adherence are not modelled by a simple causal link.

In addition, literature on factors affecting the implementation of ART programmes revealed that the implementation of ART programmes is moderated by a number of factors discussed earlier. Therefore, although it is logical that the CARG programme leads to improved ART health outcomes, to accept that the programmes is informed by a simple causal link might be contentious.CHAPTER THREE: RESEARCH METHODOLODYThis section looks at the methods used for data collection, analysis and presentation. The study is explorative in nature.

Research methodology is a way to systematically solve the research problem. It may be understood as a science of studying how research is done scientifically (Kohlari C.R 2004).Quantitative MethodsBurns and Grove (200:19) describe a qualitative approach as ” a systematic subjective approach used to describe life experiences and situations to give them meaning”. Parahoo (1997:59) states that qualitative research focuses on the experiences of people as well as stressing uniqueness of the individual. Holloway and Wheeler (2002:30) refer to qualitative research as ”a form of social enquiry that focuses on the way people interpret and make sense of their experience and the world in which they live”.

Researchers use the qualitative approach to explore the behaviour, perspectives, experiences and feelings of people and emphasize the understanding of these elements.Advantage of qualitative methods in exploratory research is the use of open ended questions and probing gives participants the opportunity to respond in their own words, rather than forcing them to choose from fixed responses, as quantitative methods do (fhi360, 2002). Opened ended questions have the ability to evoke responses that are meaningful and culturally salient to the participant, unanticipated by the researcher, rich and explanatory in nature (FHI360, 2002).Research DesignBurns and Grove (2003:195) define a research design as ”a blue print for conducting a study with maximum control over factors that may interfere with the validity of the findings”. Parahoo (1997:142) describes a research design as ” a plan that describes how, when and where data are to be collected and analysed”. Polit et al (2001:167) define a research design as ” the researcher’s overall for answering the research question or testing the research hypothesis”.

The study uses both descriptive approach.Descriptive Research DesignThe descriptive design is suitable for bringing out the characteristics and functions of the CARGs. Descriptive studies do not make an attempt to analyse the links between exposure and effect, they are limited to the description of an occurrence under investigation (Beaglehole, Bonita ; Kjellestrom, 2006). This design describes the phenomenon under study based on available data or data collected from research participants.Descriptive research may be a pre cursor to future research because it can be helpful in identifying variable that can be tested. A researcher will be looking at the health outcomes for the community members in Kwekwe district.

The findings will point the researcher to specific variables that may be impacting health that warrant further study.The data collection allows for gathering in-depth information that maybe qualitative (observations or case studies) in nature. This allows for a multifaceted approach to data collection and analysis.Population and SampleSample SizeThis refers to the number of items to be selected from the universe to constitute a sample. The size of sample should be neither excessively large, nor too small. It should be optimum.

An optimum sample is one, which fulfils the requirements of efficiency, representativeness, reliability and flexibility (Holloway and Wheeler (2002:118). A sample of 50 respondents will be used for the purpose of this research. The respondents will be classified into two categories for purposes of this research, primary and secondary respondents. Primary respondents are those directly involved in the day to day activities of the CARGS and secondary respondents are those who have an oversight role and some are just ordinary members of the community not in CARGs.Target Population Total of 30 Primary respondents will be interviewed, these include active CARG members and they will be purposively selected from existing CARGs in the selected communities served by the three health facilities. These respondents will be able to provide insights on the role of CARGs, effect and areas of improvement.

From the 30, twenty (20) respondents will be selected from three health facilities namely Sherwood clinic, Torwood clinic and Zhombe district hospital. Three (3) in depth interviews with health personnel (preferably sister in charge for the selected facilities will also be interviewed. Village Health Workers (5) will also be interviewed and 2 community leaders. All these beneficiaries will be responding to the needs of all the objectives of the study.A total of 15 Secondary respondents will be interviewed: these are selected to tell the other side of the story by narrating how they view the CARG model. These secondary beneficiaries will be selected from the same areas where the CARGs has been functioning. Interviewing secondary beneficiaries will provide answers to the objective seeking understanding of the role of CARGs.

Three (3) key informant interviews will be interviewed from the following sectors one from FHI360, an NGO facilitating the formation of CARGs in Kwekwe, Ministry of Health official (district community nurse/sister) and District aids coordinator from National AIDS Council.SamplingThe study will adopt probabilistic methods of sampling. Respondents will be purposively selected from selected CARG groups since it is a defined subset with same characteristics.Non-Probability SamplingNon probability sampling is that sampling procedure which does not afford any basis for estimating the probability that each item in the population has of being included in the sample (Kothari 2004). It involves the selection of elements based on assumptions regarding the population of interest, which forms the criteria for selection. Hence, because the selection of elements is non-random, non-probability sampling not allows the estimation of sampling errors…Battaglia, M.

P (2008). This methods was selected because of its cost effectiveness and time effectiveness compared to probability sampling.Purposive SamplingThis entails non probabilistic sample based on characteristics of a population. It uses a concept of Maximum Variation Sampling- is to look at a subject from all available angles, thereby achieving a greater understanding. Also known as ”Heterogeneous Sampling”, it involves selecting candidates across a broad spectrum relating to the topic of study. Battaglia, M.

P (2008). Key informant respondents selection is guided by type and amount of information they have. One major advantage of this type of sampling is that it is easier to generalize about your sample compare to say, a random sample where not all participants have the characteristic you are studyingData Collection MethodsKey informant- Interview- are ideal for collecting data on individuals’ personal histories, perspectives and experiences, particularly when sensitive topics are being explored (FHI360, 2002). Health professionals and non-governmental organisations staff will be targeted as key informants largely because of their comparative advantage in working with CARGsIn Depth InterviewsData Presentation and AnalysisQualitative data will be managed in the NVIVO 10 software. Thematic analysis will be done responding to the themes guided by the research objectives.

ReferencesAjzen, I (1991). The theory of planned behaviour. Organisational behaviour and human decision processes 50.2 (1991):179-211Amico, K. R., Toro Alfonso, J., & Fisher., J.

D (2005). Am empirical test of the information, motivation and behavioural skills model of antiretroviral therapy adherence. AIDS Care, 17 (6), 6661-673.doi: 10.1080/095401205Bandura, A. ”Social cognitive theory of self-regulation”. Organisational behaviour and human decision processes 50.

2 (1991):248-287Bangsberg, DR., Perry., Charlevois, E.D., Clark, R. A.

, Robertson., Zolopa, A.R. & Moss, A. (2001).

Non adherence to highly active antiretroviral therapy predicts progression to AIDS. AIDS, 15 (9), 1181-3. Retrieved from: http://journals.Iww.com/aidsonline/Citation/2001/06150/Nonadherence to higly active antiretroviral.15.

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Non Probability sampling. Encyclopaedia of Survey Research Methods. 2008. SAGE Publications, 1-4Burns, N, & Grove S. K. 2003. Understanding nursing research.

3rd ed. Philadelphia: Saunders Company.Cawley C, Nicholas S, Szumilin E, Perry S, Amoros quiles I, Masiku C, et al, Six monthly appointments as a strategy for stable antiretroviral therapy patients: evidence of its effectiveness from seven years of experience in a Medecins Sans Frontieres supported programme in Churadzulu district. Paper presented at: Malawi 21st International Conference (AIDS 2016); 2016; Durban, South AfricaCreswell, J.W. (1998). Qualitative Inquiry and Research Design: Choosing Among Five Traditions. Thousand Oaks, CA: SageDecroo T, et al (2014).

Four year retention and risk factors for attrition among members of community ART groups in Tete, Mozambiques. Trop Med Int Health.; 19 (5): 514-21 found on ww.

msf.orgDonaldson, S I. (2007). Program theory driven evaluation science: Strategies and applications. New York: Taylor & Francis GroupFHI, (2002).

Family Health International volume, Qualitative Methods: A Field Guide for Applied Research in sexual and Reproductive Health.FHI360, (2016). Zimbabwe HIV Care and Treatment Standard Operating Procedure for Community ART Refill Groups.Fisher, J.

D., Fisher, W. A., Amico, K.R., & Harman, J (2006).

An information- motivation behavioural skills model of adherence to antiretroviral therapy. Health Psychology, 25 (4), 462.Holloway, Wheeler, & IS. (2002). Qualitative research in nursing. Second edition. Oxford: Blackwell Publishing.Luque- Fernandez MA, Van Custem G, Goemaere E, et al.

Effectiveness of patient adherence groups as a model of care for stable patients on antiretroviral therapy in Khayelitsha, Cape Town, South Africa. PLoS Med. 2013;8Machitinger, E. l., & Bangsberg, DR.

(2005). Adherence to HIV antiretroviral therapy. HIV Insite. Retrieved from http://hivinsite.ucsf.

edu/insite?page+kb-17-04-18Ministry of Health and Child Care (MOHCC) (2017), Zimbabwe. Zimbabwe Population Based HIV Impact Assessment (ZIMPHIA) 2015-16: First Report. Harare, MOHCC. July 2017Mody a, et al (2017). Improved retention with longer follow up intervals for stable patients in Zambia. Conference on Retroviruses and Opportunistic Infections.

Seattle, Washington, USA.Mohcc (2011). Health Transition Fund, A Multi-donor Pooled Transition Fund for Health in Zimbabwe, Supporting National Health Strategy to improve access to quality health care in ZimbabweMOHCC (2013), Zimbabwe Care and Treatment Strategic Plan 2013-2017. HIV MOHCCMOHCC (2013), Zimbabwe Care and Treatment Strategic Plan 2013-2017. HIV.Mutasa-Apollo T, Ford N, Wiens M, socias ME, Neussie E, Wu P, Popoff E, et al. Effect of frequency of clinic visits and medication pick up on antiretroviral treatment outcomes: a systematic literature review and meta-analysis. J Int AIDS Soc.

2017; 20 (Supply 4).Myer LLV, Zerbe A, Phillips TK, Brittain K, Mukonda E, Allerton J, et al. Differentiated models of care for HIV infected postpartum women receiving antiretroviral therapy in Cape Town, South Africa: a cohort study. J Int AIDS Soc. 2017; 20 (Suppl 4): 21636Nsanzimana SRE, Rnakare M, Burns T, Dludlu S, Mills EJ, CondoJ, et al. Phased implementation of spaced clinic visits for stable HIV positive patients in Rwanda to support Treat All. J Int AIDS Soc. 2017; 2017; 20 (Suppl 4): 21649.

Parahoo, K. (1997). Nursing research: Principles, processes and issues. London: MacMillian Press.Pasipamire L, Kerschberger B, Zabsonre I, Ndlovu S, Sibanda G, Mamba S, et al. Rapid implementation of combination ART refill models in rural Swaziland.

Paper presented at 21st International AIDS Conference (AIDS 2016); 2016; Durban, South AfricaPatton, M.Q. (2002). Qualitative Research and Evaluation Methods, 3rd Edition. Thousand Oaks, CA: SagePolit, Det al (2001) Essentials of Nursing Research: Methods, Appraisal and Utilization. Philadelphia, PARobert W et al, (2013). Examining the Link between Patient satisfaction and Adherence to HIV Care: A Structural Equation Model (online journal).

Rosen S et al. Retention in care between testing and treatment in Sub Saharan Africa: HIV a systematic review. Medicine, 2011, 8:e1001056 PLSarna, A., Lutchers, S.

, Geibel, S., Chersich, M. F., Munyao, P., Kaai, S.

, Mandaliya, K.N., Shikely, K. S.

, Temmerman, M., & Rutenberg, N. (2008). Short and long term efficacy of modified observed antiretroviral treatment in Mombasa, Kenya: a randomized trial. JAIDS Journal of Acquired Immune Deficiency Syndromes, 48 (5), 611-619Skovdal, m et al.

in press. ”masculinity as a barrier to men’s uptake of HIV Services in Zimbabwe,” Globalization and HealthSteele, R G., ; Grauer, D. (2003). Adherence to antiretroviral therapy for paediatric HIV infection: Review of the literature and recommendations for research. Clinical Child and Family Psychology Review, 6, 17-30.

Retrieved from http:/link.springer.com/journal/10567UNAIDS. 90-90-90. an ambitious treatment target to help end the AIDS epidemic.

2014. http://www.unaids.

org/en/resources/documents/2014/90-90-90.Accessed 20 July 2017World Health Organization, 2013. Consolidated Guidelines on the Use of Antiretroviral Drugs for treating and Preventing HIV infection: Recommendations for a Public Health Approach. Geneva: World Health Organisation.World Health organisation, 2008. Operations manual for delivery of HIV prevention, care and treatment at primary health centres in high prevalence, resource constrained settings.

Edition 1 for field testing and country adaptation. http://www.who.int/hiv/pub/imai/operations manual/en/. Accessed 16 Sept 2017Taiwo, B.

O., Idoko, J. A., Welty, L. J., Otoh, I.

, Job , G., Iyaji, P. G., Agbaji, O., Agaba, P. A., ; Murphy, R.

L. (2010). Assessing the viorologic and adherence benefits of patient selected HIV treatment partners in a resource limited setting. J AIDS Journal of Acquired Immune Deficiency Syndromes, 54 (1), 85-92Visnegarwala, F., Rodriguez-Barradas, M. C., Graviss, E.A.

, Caprio, M., Nykyforchyn, M., ; Laufman, L.

(2006). Community outreach with weekly delivery of antiretroviral drugs compared to cognitive behavioural health care team based approach to improve adherence among indignent women newly starting HAART. AIDS care, 18 (4), 332-338Van Loggerenberg, F., Grant A.

D., Naidoo, K., Murrman, M.

, Gengiah, T. N., Fielding, K., ; Karim, S. S. A. (2014). Individualised Motivational Counselling to Enhance Adherence to antiretroviral Therapy is not Superior to Didactic Counselling in South African Patients.Williams, A. B. E., Fennie, K. P., Bova, C. A. A. N. P., Burgess, J. D. A.C.R.N., Danvers, K. A., ; Dieckhaus, K. D. (2006). Home visits to improve adherence to highly active antiretroviral therapy: a randomized controlled trial. JAIDS Journal of acquired Immune Deficiency Syndromes, 42 (3), 314-321Coetzee, D., Hildebrand, K., Boulle, a., maartens, G., Louis, F., Labatala, V., ; Goemaere, E. (2004). Out comes after two years of providing antiretroviral treatment in Khayelitsa, South Africa. Aids, 18 (6), 887-895Barnabas RV, Van Rooyen H, Tumwesigye et al. Initiation of antiretroviral therapy and viral suppression after home HIV testing and counselling in KwaZulu-Natal, South Africa, and Mbarara district, Uganda: a prospective, observational intervention study. Lancet HIV. 2014; 1:e68-e76Wouters e, Van Damme W, Van Loon F, Van Rensburg d, Meulemans H: Public sector ART in the Free State Province, South Africa: Community Support as an important determinant of outcome. Soc Sci Med. 2009, 69 (8): 1177-1185. 10.1016/j. socscimed. 2009.07.034C. Reis, M. heisler, L.L. Amowitz et al.,, Discriminatory attitudes and practises by health workers toward patients with HIV/AIDS in Nigeria,” PLoS Medicine, vol. 2, no. 8, pp. 743-752. 2005.

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CHAPTER (2001) defined credit risk as the possibility

Industry

CHAPTER ONE: INTRODUCTION1. Background of the StudyFinancial institutions have undergone challenges over the years for various reasons.

The main cause of concern is related to credit standards of borrowers and peers arising from poor loan appraisals and adherences to set credit policies (Bolton, 2011). With the adequate management of credit risk in financial institutions (FIs), survival and growth of the FIs is guaranteed. FIs play a critical role in the economy similar to that of blood arteries in the human body in that they pump financial resources for economic growth from depositories to where they are required (Shanmugam and Bourke, 1992). In the case of Savings and Credit Cooperative Societies (SACCOs), credit risk is of much concern due to the high levels of perceived risks arising from the characteristics of customers and the conditions that they find themselves in. Besides providing loans and offering financial services like investments, SACCOs safeguard money and other valuables for their members. The main income generating activity for SACCOs is credit creation.

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This activity however entails huge risks to both the lender and the borrower. There is risk of a member not fulfilling their contractual obligation and this can greatly damage the seamless functioning of the lender’s business. On the other hand, a lender with high credit risk has a high bankruptcy risk, which places its members’ funds in danger. Credit risk is a major concern to SACCO authorities and Government regulators for the reason that it can easily lead to the failure of a SACCO (Jong, 2008).The Basel committee on SACCO supervision (2001) defined credit risk as the possibility of losing the outstanding loan partially or totally, due to credit events (default risk). Credit risk management is an approach to managing uncertainties through assessing risk and coming up with strategies to manage and mitigate it. Some of the well-known strategies used in risk management are: to transfer to another party, to avoid the risk, to reduce the adverse effects of the risk, and to accept some or all the effects of the risk (Richard, 2006).The overall aim of credit risk management is to maximize a SACCO’s risk- adjusted rate of return by maintaining credit risk exposure within predetermined parameters.

SACCOs must manage credit risk inherent in their portfolios together with the risk involved in individual credit transactions (Mwega, 2009). It is paramount for a SACCOs to generate credit guidelines to serve as a blueprint for making investment and lending decisions. Boyd (2010) asserts the necessity of establishing a stable credit risk environment, a fluid credit granting processes, sound credit administration and measurement procedures, and monitoring and control over credit risk policy.A lot of Kenyan SACCOs have it in their credit policies to check with the Credit Reference Bureau (CRB) prior to loan issuing to borrowers (Nyaoke, 2007).

This avails the chance for the SACCO to report defaulters and at the same time, identify defaulters before they get the chance to borrow. 1.1. Savings and Cooperative Societies (SACCOs) A SACCO is an autonomous association of people who voluntarily come together with shared economic, social, cultural needs and aspirations through a jointly owned and democratically controlled enterprise. Regardless of their deposit amounts, members have equally take part the active management and administration of the SACCO whereby duties are shared (Tummala and Burchett, 1999). The key objective of a SACCO is to promote by mutual aid the economic and social welfare of its members by granting loans to cover their economic needs, support the spirit of initiative in agricultural or industrial work and careful use of the savings produced locally (WOCCU, 2005).

The first cooperative society in Kenya was started by European settlers in the Rift Valley back in 1908. The society’s aim to market cereal crops, fruits and dairy products. At the time there was no Cooperative Law to govern it up until 1931. In 1966, the Cooperative Societies Act was enacted, which then introduced control measures to counteract mismanagement and misappropriation of funds. SACCOs have grown significantly and so has their role in providing financial services to majority of Kenyans.

Between 1985 and 2006, the number of registered SACCOs rose from 1285 to 4876 (Ministry of Co-operative Development and Marketing, 2007).The Kenya Union of Savings and Credit Cooperatives (KUSCCO) ltd was registered on 27th September 1973 and officially began its operations in 1974 as the umbrella organization of all SACCOs in Kenya. KUSCCO was then admitted to WOCCU in February 2009. Since then, there has been fast growth enabled by rapid diversification in various product developments to meet the dynamic members’ financial needs.

This is evident from the financial performance, which has greatly improved with an asset base of over Kshs. 200 billion and a total savings exceeding Kshs. 170 billion. There has also been an increase in dividend rate payment of 9% as well as share capital growth from KShs.253 million in 2007 to KShs.301 million in 2008 (WOCCU, 2010).SACCOs differ from banks in the way members use the financial intermediaries.

SACCO members typically have a common bond based on either employer, community, geographic area, industry or other affiliation. Examples are Mwalimu SACCO, Kenya bankers SACCO, Kenya Bus Services SACCO, among others. SACCOs have reached both public and private sectors of the society and hence have developed a much broader and deeper market penetration. This goes a long way in contributing to the government’s goals of financial inclusion as they are better positioned to continue serving the ‘unbanked’ population (WOCCU, 2009). The Kenya SACCO System registered under Cooperative Societies Act, Chapter 490, is the largest credit union network in the whole of Africa with about 5,000.

00 SACCOs currently registered in Kenya (Ministry of Co-operative Development and Marketing, 2008).SACCOs are preferred over banks due to the immense difference in interest rates. SACCOs offer between 1 percent to 1.5 percent per month, while banks offer an interest of 14 percent. SACCO interest rates are constant over the loan’s lifespan and do not charge extra to obtain these loans. Additionally, SACCOs provide lucrative investment opportunities to members through their share owning options (Mso Muga, 2017).SACCOs have good diversity across various union members of different types, industry sectors and geographies; like the Kenya Bus Services SACCO, Kenya Planters Cooperative Society, Kenya Creameries Cooperative, etc.

Diversification strategies hedge credit risk to avoid concentration of credit risk problems (Bessis, 2003). SACCOs enhance credit by buying credit protection in the form of guarantees from financial guarantors. Credit scoring is another credit risk management technique where the SACCO analyzes a borrower’s risk. A good credit scoring model must be highly discriminative whereby high scores reflect almost no risk and low scores correspond to very high risk or the opposite depending on the sign condition (Bessis, 2003). Credit approval is where the lending limit is a multiple of savings.

This technique aids in building a savings-led institution and allows for the institution to learn about the discipline and economic capacity of memebers by observing frequency of deposits. Credit unions must have in place written guidelines on credit approval process, approval authorities of individuals or committees as well as decision basis (Mwisho, 2001).1.2. Waumini SACCOWaumini SACCO is a Savings and Credit Cooperative Society that was registered in 1980 under the Cooperative Societies Act of the laws of Kenya. The SACCO mobilizes saving and deposits, and economically empowers its members by extending credit. Waumini SACCO has grown in membership and provides inclusive service offerings to individuals, corporate institutions and organized Catholic Church groups.

It is currently a leading progressive SACCO with membership of over 21,000 from over 800 catholic institutions across 26 Catholic Dioceses in Kenya, Catholic Church faithful and past employees of Catholic institutions “Mzalendo” (Waumini, 2017).Waumini’s objectives are: to accept deposits and advance loans to members, to promote economic and social development by availing affordable credit to customers and to continuously educate members on co-operative and economic development. It bases its operations on its core values (competence, teamwork, servant leadership, justice and fairness, transparency and accountability, innovation and creativity, customer care, honesty and integrity). Waumini Sacco offers loans of up to three times the savings of its members. They offer personal loans, emergency loans, development loans, jaza loans, bridging facility and purchase loans. The loans offered attract fixed interests, which are charged on reducing balance. Loan repayment is usually from one up to sixty months.

The loans are charged an interest rate of 7% upfront (Waumini, 2017).Within the past two years Waumini S acco has realized a growth of 17.6% in its asset base which continues to solidify the stability of the Sacco. The membership has grown from 19.7% compared to 11% in 2016, a total of 4,256 new members were recruited compared to the annual target of 3000. Loan disbursement has grown by 12%, though it is a drop compared to 2016, that had a growth of 16% (Waumini, 2017)Waumini’s key achievements include: establishing a mobile lending platform (Waumini Cash) that enables members to apply for loans at their convenience through cell phones; launching two branches and a liaison office in 2016; developing digital and social media networks through its interactive website; achieving capital adequacy requirements set out by SASRA; and increasing the requirements of Catholic and Corporate institutions.

The SACCO however faces some challenges such as defaulting units arising from financial constraints. This affects its performance as it is forced to make provisions for non-performing loans. Another challenge is that most Catholic institutions are funded by local and international donors who have substantially cut their financial support to the said institutions. What this does is that it increases the vulnerability of these institutions to financial difficulties to the point of closure. This has resulted to member reduction, deposit withdrawals and some cases of unit default (Waumini, 2017).1.

3. Statement of the ProblemSACCOs are pivotal in serving the financial requirements of economic players such as households and SMEs. They encourage individuals to save, thereby accumulating capital for the economic development of Kenya. Lending has been and still is the backbone of financial institutions and this is truer to emerging economies of developing countries such as Kenya where capital markets are not yet well developed (Richard, 2006). In today’s rapidly changing business environment, there have been cases of worsening economic conditions, monetary policy changes, financial sector liberation and more importantly, stiff competition (Nyaoke,2007). All these pose different risks to financial institutions including credit risk. Credit risk management practices will therefore help SACCOs to reduce their exposure to credit uncertainties and enhance their ability to compete with other well-established financial institutions like banks (Iqbal and Mirakhor). According to Waumini’s 2017 annual report, the SACCO has faced several challenges such as default by some units due to financial constraints, withdrawal of international donors who are their main source of funding and poor employee renumeration compared to existing market rate and economic fluctuation which affects members borrowing power.

All these challenges increase the risk default. Therefore, there exists a need to address the issue of credit risk default to reduce the default rate. Reduction of the SACCO’s exposure to credit risk will enhance its ability to achieve its predetermined objectives and ascertain its success, thus necessitating the need to have in place comprehensive credit risk management practices and reporting process to identify, measure, monitor, manage, report and control credit risks.

Adequate credit risk evaluation and management practices can be identified, and the risk controlled so that management can take certain steps to improve the SACCO’s potential for success (Saunders and Cornett, 2002). Considering the importance of lending in financial institutions, the future of SACCOs undoubtedly rests on Credit Risk Management (Bessis, 2012). In Kenya, different scholars have reviewed various aspects of credit risk management. (Muasya, 2009) studied the impact of non-performing loans on the financial performance of banks in Kenya while (Omina, 2009) studied the relationship between credit risk management and non-performing loans in commercial banks. Wambugu (2008) studied credit risk practices by Micro Finance Institutions (MFIs) in Kenya and the findings were that most MFIs had clearly defined credit policies that were periodically reviewed. (Ngare, 2008) researched on credit risk management practices by Commercial Banks in Kenya.While the above research outcomes provide insight on credit risk management techniques by commercial banks and MFIs, there is little known study to the researcher that has been done on credit risk management in SACCOs and how they impact on their financial performance.

This is the knowledge gap the study sought to address by answering the research question: what is the impact of Credit Risk Management practices on financial performance of SACCOs in Kenya?1.4. Research Objectives1.4.1. General ObjectivesTo find out the effects of credit risk management practices on financial performance of SACCOs in Kenya.1.

4.2. Specific Objectives1.

To determine the effect of credit scoring on financial performance on SACCOs.2. To find out the effect of credit administration on financial performance of SACCOs.3. To establish the effect of credit policies on financial performance among SACCOs.4.

To assess the effect of credit risk monitoring on financial performance among SACCOs.1.5. Research Questions2. What is the effect of credit scoring on financial performance of SACCOs?3. What is the effect of credit administration on financial performance SACCOs?4. What is the effect of credit policies on financial performance among SACCOs?5. What is the effect of credit risk monitoring on financial performance among SACCOs?1.

6. Significance of the studyThe study will help SACCO authorities and management to appreciate the need for credit risk management and to create or review credit risk management practices as well as their impact on financial performance. The study will also assist government agencies in developing regulatory and legislative frameworks that will guide SACCOs in developing and adopting sound credit risk management practices in Kenya. The study will add to the existing knowledge of credit risk management practices as a whole. Finally, this study will provide a basis for future research.1.

7. Conceptual Framework The conceptual framework shows the relationship between the independent variables (Credit Risk Management strategies) and the dependent variable (financial performance of SACCOs) that were investigated in this study. The independent variables entailed Credit Scoring, Credit Administration, Credit Policies and Credit Risk Monitoring. Financial performance (the dependent variable) can be analyzed using the recommended measures for financial analysis; which are grouped into five broad categories: liquidity, solvency, profitability, repayment capacity and financial efficiency. Profitability measures the extent to which a business generates profit. Four useful measures of profitability are the rate of return on assets (ROA), the rate of return on equity (ROE), operating profit margin and net income. The ROA measures the return to all assets and is often used as an overall index of profitability, and the higher the value, the more profitable the business.

Since ROA reflects the efficiency of how the assets (loans) under the control of management are used to earn income, it is an intuitively a robust measure of performance; therefore, this study measured financial performance using ROA. CHAPTER TWO: LITERATURE REVIEW2. IntroductionThis chapter discusses the strategic approaches to credit risk, empirical review of credit monitoring and recovery strategies and lastly, the chapter summary.2.

1. Theoretical FrameworkThis research study was guided by three theories namely; portfolio theory to credit risk management credit, theory of internal controls and risk theory.2.2.0 Portfolio Theory to Credit Risk Management From the 1980’s, credit unions have been able to use the Modern Portfolio to market risks. Several are currently applying the value at risk models to handle their interest rate and exposures to risks in the market. According to Korir (2012), the negative impact of credit concentration on financial performance has been noted by credit institutions.

Hence, a good number of credit institutions are now using approaches that are more quantitative in nature as an approach to credit risk management. It is noted that steps forward are being made towards formulating new ways of measuring credit risk based on an institution’s entire portfolio. The use of credit derivatives is also being employed for efficient transfer of risk while maintaining customer relationship. 2.2.1.

Theory of Internal Controls Effective internal controls greatly affect the smooth operations of an organization and how that organization achieves its goals. Controls contribute towards meeting of long-term objectives and also towards maintaining dependable financial reporting. Internal controls enable organizations to comply with rules and regulations, as well as policies laid down internally. This in turn reduces the risk of unexpected losses and damages to company reputation (Barnabas, 2011). This theory brings forth the indication that there should be transparency, guiding policies and controls to curb misuse of funds that will lead to poor financial status of the SACCO.2.2.2.

Credit Risk Theory The Credit Risk Theory, introduced by Melton in 1974, notes that a default event derives from an institution’s asset evolution, modeled by a process with constant parameters. These models are typically structural and based on the issuer specific variables. Losses in this category due to default are because of factors outside the lender’s control but that are specific to that industry (Longstaff and Schwartz.1995). 2.

2.3. Credit Scoring Credit scoring analyzes a borrower’s risk. Credit scores are assigned to each member to indicate risk level. A good credit scoring model must be highly discriminative whereby high scores reflect almost no risk and low scores reflect very high risk or the opposite depending on the sign condition. The more discriminative the scoring system is, the better the ranking (Bessis, 2003).

Previously, credit scoring focused on measuring the risk that a customer would not fulfill his/her contractual obligation. Recently, credit scoring evolved to loss and exposure risk as well. Nowadays, scoring techniques are used throughout the whole life cycle of credit as a decision support tool for large member bases.

In the past, the credit approval decision was made using a purely judgmental approach by just inspecting the application form details of the applicant and commonly focused on the values of the 5 Cs (character, capital, collateral, capacity and conditions of a customer) (Pykhtin, 2005). Character measures the borrower’s personal character and integrity and includes virtues like reputation, honesty and their willingness to comply with credit terms and conditions. Capital measures the difference between the borrower’s assets which may include car, house and liabilities like renting expenses and whether they exist; Collateral evaluation of the assets provided security in case payment problems occur, for example house hold assets, house, car. Capacity measures the borrower’s ability to pay based on for instance, job status, source of income. Conditions where the members’ borrowing circumstances were evaluated, for example, market conditions, competitive pressure, and seasonal character (Pykhtin, 2005). 2.2.4.

Credit Approval and AdministrationClearly established processes of credit approval and oversight and extending existing credits has been observed to be very important in the management of credit risk in SACCOs. Credit institutions must have in place written guidelines on credit approval process, approval authorities of individuals or committees as well as decision basis and the board should always monitor loans. Approval authorities cover new credit approvals, renewals of existing credits and changes in terms and conditions of previously approved credits particularly credit restructuring, which should be documented and recorded (Mwisho, 2001). The approval process should be based on a system of checks and balances. Some approval powers should be reserved for the credit committee, considering the size and complexity of the credit transaction. The institution, depending on its size, should have a group of experts to critically assess, approve and manage credit risk. Accountability should also be established and maintained for the decision-making process, together with periodic audits of decisions taken and relevant individuals involved (Caoutte, Altman and Narayanan, 1998).

All credit approvals should be at an arm’s length, based on established criteria. Credits to related parties should be closely analyzed and monitored so that no senior individual in the institution is able to override the established credit granting process (Derban, Binner and Mullineux, 2005). 2.2.5. Credit PoliciesMwisho, (2001) indicated that credit institutions should have written loan policies approved by the board in the financial institutions. The board should review the policies annually and revise where needed. The loan policy should include the policy objective, eligibility requirements, permissible loan purposes, acceptable types of collateral, loan portfolio diversification requirements, loan types, interest rates, terms, frequency of payments, maximum loan sizes per product type, maximum loan amounts as a percentage of collateral values, member loan concentrations, restrictions on loans to employees and officials, loan approval requirements, monetary loan limits, loan documentation requirements and cosigner requirements.

Credit institutions should also develop lending procedures which are developed by the operational management teams responsible for ensuring they are indicative of current lending practices. 2.2.

6. Credit Monitoring An effective credit monitoring system will include measures to: ensure that the institution understands the current financial condition of the borrower; ensure that all credit follows the existing policy; ensure that projected cash flows on major credits meet debt servicing requirements; and ensure that collateral provides adequate relative coverage (Greuning & Bratanovic 2003). The monitoring of borrowers is very important as current and potential exposure changes with time therefore, credit monitoring involves frequent contact with borrowers, creating an environment that the SACCO can be viewed as a solver of problems and trusted advisor to the borrower (Tracy & Carrey 1998; Basel 1999). Therefore, SACCOs need to develop and implement in-depth procedures and information systems that keep track of the condition of individual credits and obligors across SACCOs (Basel, 1999). 2.

2.7. Financial PerformanceProfitability can be broken down into two components; profit margin and turnover. High turnover is an indication of efficiency in asset utilization. (Barton & Gordon, 1998.) A company’s financial performance is positively influenced by its total assets, where the greater the amount of assets, the less risk involved. Studies have sought to investigate the connection between financial performance and turnover, but they have mostly been inconclusive (Chijoriga, 2007). According to SASRA (2015), Waumini SACCO had total assets worth Kshs.

2, 773, 956, 585; total deposits worth Kshs. 2, 158, 733, 453; net loans worth Kshs. 2, 470, 796, 743; and total income of Kshs. 323, 231, 873.

In 2016, Waumini’s total assets were Kshs. 3, 221, 340, 000; total deposits were Kshs. 2, 500, 410, 000; net loans were Kshs.

2, 866, 840, 000; and turnover was Kshs. 386, 670, 000. Going by these figures, the ROA was approximately 11.65% in 2015 and approximately 12.003% in 2016.2.

3. Summary of Literature ReviewThe study reviewed three theoretical foundations; portfolio theory to credit risk management., the theory of internal controls and credit risk theory. The empirical review looked at relevant studies relating to the topic and some determinants of financial performance. 2.4. Empirical Review2.4.

1. Global StudiesAn increased investment by financial institutions in risk management led to a reduction in how volatile earnings and losses were during the recession of 2001 (Drzik, 2005). A research by Tucker and Miles (2004) looked at three series of data for the period between March 1999 to March 2001 and that micro finance institution that were self-sufficient performed better and were more profitable, based on ROE and ROA, as compared to their counterparts in the third world countries and others that had not become self-sufficient. Hakim and Neamie (2001) conducted a study in Lebanon and Egypt where they looked at the performance of banks based on the use of credit risk practices. The results reveal that variables of credits and profitability positively correlate.2.

4.2. International Studies (Africa)Nawaz and Munir (2012) conducted a study on credit risk and the financial performance of banks in Nigeria. The data included a cross section on loans and advances, non-performing loans, total deposits, profit after tax and total assets of the sampled banks and correlation models were used to analyze the data. The study concluded that credit risk management had an important impact on the profitability of banks in Nigeria.

From this finding, they recommended that management carefully set up policies on credit that will enhance profitability and understand how these policies affect banks operations.Mutara Development SACCO has a formalized their credit policy manual that clearly sets out the loan application, appraisal and approval procedures as well as requirements for the various loan products offered by the institution. The institution has further benefited from an improved portfolio management methodology through its partnership with the Microfinance Support Centre Limited, to which it reports bi-monthly (Planet Rating East Africa, SACCO growth Report, 2007). 2.4.3. Local Studies (Kenya)Kalui & Kiawa (2015) researched the effects of credit risk management procedures on financial performance among microfinance institutions (MFIs) in Kenya.

The objectives were to determine to what extent risk identification, risks monitoring procedures, and risk analysis and assessment procedures are applied in credit risk management and their overall effect on the financial performance. The findings concluded that these procedures were critical as they ensured the task of managing risk was established in the entire institution. Kiplimo & Kalio (2012) investigated how loan performance of MFIs in Baringo County was influenced by credit risk management practices. Their findings were that there exists a positive relationship between client appraisals and performances of loans. The study therefore exerted that loan performances of MFIs in Baringo County were influenced to a greater extent by credit risk management practices.

Gaitho (2010) conducted a survey on credit risk management practices by SACCOs in Nairobi. The objective of the study was to identify credit risk management practices adopted by SACCOs in Nairobi. The findings show that most SACCOs used credit risk management practices to objectively appraise risks in credit distribution. Majority of the respondents agreed that credit risk management practices have impacted positively to their organizations by ensuring efficiency in carrying out its obligations and in meeting its objectives. 2.5 Knowledge GapMost researchers have done studies on Saccos and MFI’S in Kenya, but none have researched on Waumini which the scope of study in this particular research is.CHAPTER THREE: RESEARCH METHODOLOGY3.

1. Introduction This chapter looks at the methodology used in the context of this study to find answers to the research questions. The research methodology comprises of the research design, target population, sampling procedure, data collection methods, and data processing and data analysis techniques. The following sections provide a detailed description of the methodology utilized in the study.3.

2. Research Design This study adopted a descriptive survey design that aimed to explore the Credit Monitoring and Recovery strategies adopted by SACCOs in Kenya. A descriptive research design is used for this research study as this will provide answers to the questions related to the research problem (Given, 2007). Descriptive designs result in a description of the data, either in words, pictures, charts, or tables, and indicate whether the data analysis shows statistical relationships or is merely descriptive. Census survey based on the SACCOs in Kenya was used to produce results that were broad, credible and conclusive. The research was quantitative in nature and relies on primary data obtained from Waumini SACCO.3.3.

Population Population is a compute set of individuals, events or objects having a unique characteristic that can be observed (Mugenda ; Mugenda, 2003). In this study the target population is employees of Waumini Sacco.3.4. Sample designA sample design is a method of choosing a section of the entire population is called sampling (Chandran, 2004). For this study the researcher made use of the probability random sampling method. 3.

5. Sample size and sampling techniqueAccording to Mugenda and Mugenda (2003) a sample size of 10% to 30% is considered desirable. The study sample size (n) is 20% percent of the entire population. The descriptive method used will assist the researcher to make a conclusion from the sample. Random sampling technique has been used in this study.3.

6. Data Collection The researcher used a structured questionnaire as primary data collection instrument. The questionnaire was considered appropriate because it was more convenient to administer and to collect data to enable the achievement of the objective of the study. The primary data collected in the study included data on credit monitoring and recovery strategies adopted by SACCOs.The questionnaire contained closed-ended questions and open-ended questions structured into various sections to avoid rigidity and allow for quantification of data. The questionnaire was targeted to the heads of departments and staff involved in credit monitoring and recovery in the SACCO.3.

7. Data Analysis Data analysis is a systematic way of looking for patterns in the collected data and coming up with ideas which account for the account of those patterns (Newton and Jeonghun, 2010). The research questions of the research study are to be answered through data analysis. Data analysis also assists in determining the relationships and trends among variables. The content analysis technique is to be used to analyze the data collected and thereafter the findings that emerged from the analysis are to be used in the report compilation.

The researcher will use qualitative and quantitative techniques in analyzing the data. After receiving questionnaires from the respondents, the responses will be edited, classified and tabulated to analyze quantitative data. Tables and charts will be used for presentation for easy understanding. This will be coupled with factoring analysis on qualitative issues to generalize the results. Factor analysis measures the factors that are deemed to contribute most to a particular issue under investigation, such as credit risk management practices, based on statistics drawn from questionnaire responses.

CHAPTER FOUR: DATA ANALYSIS, RESULTS AND INTERPRETATIONS 4. Introduction In this chapter, results and findings gathered from responses will be presented. First, descriptive statistics will be applied using statistical measures in order to understand the nature of the results. 4.1. Response Rate Fifty (50) questionnaires were distributed to offices of Waumini SACCO, out of which thirty (30) were dully completed and picked by the researcher from the respondents.

The rate of response was then calculated at 60%, which is in concords with Mugenda and Mugenda (2003). They hold a response rate of 50% as being sufficient for generalization while for analyzing and reports, 60% is good. The researcher informed ahead of time the potential participants after which the questionnaires were dropped off and picked up days later, giving the respondents sufficient time to answer the questionnaires accurately. 4.

1.1. Credit Monitoring The respondents were required to make indications by ticking against statement related to credit monitoring at the SACCO. It was noted that most of the respondents agreed strongly that the credit risk monitoring practices used by these entities addressed all significant risk.For a credit risk management system to be effective, it must be monitored on an ongoing basis and the structure must be reviewed constantly. The management should generate reports, ensuring that risks are identified and assessed (Al-Tamimi ; Al- Mazrooei, 2007).

?Credit Monitoring StrategiesDo the SACCO monitor loans on an ongoing basis to enforce payment?Does the SACCO generate daily, weekly or monthly reports?Does the SACCO monitor account operations of its members?The findings in table 3 shows that all the respondents (100%, n=30) indicated that the SACCO monitors loans to enforce payments. The findings in table 4 show that all the respondents (100%, n=30) indicated that the SACCO does generate daily, weekly or monthly credit reports to monitor loans and the findings in table 5 show that the SACCO strictly monitors the account operation of its members to prepare for defaulters.Does the SACCO carry out rigorous risk assessments?The findings in table 6 indicate that all the respondents (100%, n=30) indicated that the SACCO subjects credit proposals to rigorous risk assessment.

?Credit Recovery StrategiesMeasurement of RiskThe findings in table 7 indicate that 60% of the respondents indicated that they measure risk debts based on the length of time of the loan recovery. 20% indicated that they measure risk when the credit facility remains unpaid for three months. 10% indicated that they use portfolio at risk as a measurement of risk and 10% indicated that they use frequency of payments.?Strategies put in place for Debt RecoveryThe findings in table 8 show that 83.33% of the respondents are aware that credit is given out with security.

60% of respondents note that there are relationship officers that maintain good relations with clients. 33.33% of respondents say that making customer visits is one way of recovering the loans. The SACCO also uses dedicated departments in place to take care of the debt recovery as indicated by 66.67% of the respondents.

All the respondents agree on alerting customers on payment beforehand. ?Debt Recovery Strategy SuccessThe findings in table 9 indicate that all of the respondents indicated that they list the defaulters at the CRB as a strategy used to influence the success of their debt recovery. The findings also indicate that all of the respondents act on time and use demand letters. The findings indicate that 100% do monitoring of the loan portfolio and all the respondents agree on building of good customer relations as a way of ensuring the success of loan recover. All of the respondents indicated that they speed up the security realization process as a strategy of ensuring success in debt recovery.?Evaluation of Credit ApplicationThe findings in table 10 show that 70% of the respondents indicated that they use account turnover and cash flow of the customers as a way of evaluating credit application.

All the respondents indicated that they analyze the SACCO’s ability to service loans as a way of evaluating credit applications. The findings also indicate that 83.33% of the respondents evaluate credit application through request for collaterals.4.1.2.

Credit Policies The study’s findings indicate that a credit policy provides a framework for the entire management practices. It was also noted that policies have enforced the SACCO’s operational consistence. The participants agreed that credit policy has maximized the value of the Sacco. It was concluded that using policies was time saving since it prevented issues from being discussed again in future. 4.2. Discussion of Research FindingsThe study aimed to establish the effect of credit risk management practices (creditmonitoring, credit scoring, credit administration and credit policies) on the financial performance of Waumini SACCO.

The study found that respondents agreed that the SACCO uses credit scores to evaluate the potential risk posed by lending money. The findings also reveal that, in order to maintain a high level of financial performance,SACCOs should appropriately apply risk management practices. It was noted that most of the respondents agreed strongly that the credit risk monitoring practices used by the SACCO addressed all significant risk. Regarding the cultivating of good loan customers and using credit-risk analysis to ensure that borrowers were credit worthy, all the respondents agreed. On the relationship between financial performance and other variables, the study’s findings revealed that an increase in credit scoring shall result in an increment in Financial performance. Credit administration will also result in an increase in financial performance. When credit policies rise, financial performance rises as well.

Credit risk monitoring activity bump leads to an increase in the dependent variable. CHAPTER FIVE: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS 5 Introduction The chapter summarizes the research findings as presented in the previous chapter. The conclusion drawn from the findings is presented in this chapter. This chapter expresses the researcher’s recommendations and areas for further research.

5.1. Summary of Findings The general objective of this study was to determine the effect of credit risk management on the financial performance among SACCOs. The study found that most respondents agreed Waumini SACCO does an analysis of previous credit records of a borrower for the purpose of determining their credit worthiness.

Most of the respondents agreed that credit scores help to identify areas of classification. To add to that, the respondents strongly agreed that use of credit scoring has enabled the SACCO to mitigate risks. The study sought to establish the effect of credit administration on the financial performance of the SACCO. The findings show that all respondents strongly agreed that the SACCO had transparent operations and demonstrated integrity in conducting their business. The respondents also agreed that the SACCO’s administration system aids in the management and in the observation of the entire loan portfolio. The study also found that loan decisions are made in accordance with the SACCO’s loan policy.

The respondents identify with procedural guides that relate to credit score monitoring. The study further sought to establish the effects of credit policies on financial performance of the SACCOs. Further, credit policies ensure the SACCO’s operational consistency.Finally, the study sought to investigate the effects of credit risk monitoring on the financial performance of the SACCO. The respondents strongly agreed that significant risks were addressed by the risk monitoring practices put in place by the SACCO.

5.2. Conclusion The Credit Risk Management policy goes a long way in providing guidelines that aid in the management of the various risks a SACCO encounters in their core activities. Formulating a sound credit policy is largely done by SACCO members while the regulatory bodies have moderate involvement.

From the findings, the study concludes that SACCOs must have credit risk management strategies in order to run effectively and prevent it from failing in its obligations, meet both its short and long-term objectives, minimize loan default rate, and ensure that the organization performs better, competes better, thus increasing the return on assets and overall profitability. 5.3.

Recommendation The researcher recommends that SACCOs should benchmark the existing credit policies used in other financial institutions like commercial banks and micro finance institutions. These SACCOs can use existing credit policy frameworks as their blueprint; or modify them to suit the conditions surrounding them. SACCOs should also enforce internal controls and strict policies and ensure that these policies are followed to the latter.From past experiences, SACCOs have suffered credit losses through lax lending standards and unsecured loans.

The recommendation therefore is that SACCOs must create, keep track of, and constantly update personality profile assessments of future and current borrowers. This will enable the SACCO to minimize default risk by allowing through borrower insight obtained from properly structured processes.5.4. Limitations of the study The findings from this study are applicable only to SACCOs in Kenya, however, this is not a one size fits all suggestion as different SACCOs are surrounded by different factors that control their operations. The suggestions may be perfect for one institution, but they might be subpar for another.

Also, a fact worth noting is that these financial situations in the overall economy are likely to be influenced by change, the relevance of the information in these findings are limited to the duration of this research. 5.5. Suggestions for Further Research This study should be compared with findings from other SACCOs and financial institutions to establish the similarities and differences that may be evident. This will assist the SACCOs to benchmark with other organizations.

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