Kenyan Health Research Articles

Determining the effective coverage of maternal and child health services in Kenya, using demographic and health survey data sets: tracking progress towards universal health coverage.

ObjectivesEffective coverage (EC) is a measure of health systems’ performance that combines need, use and quality indicators. This study aimed to assess the extent to which the Kenyan health system provides effective and equitable maternal and child health services, as a means of tracking the country's progress towards universal health coverage.Methods and resultsThe Demographic Health Surveys (2003, 2008–2009 and 2014) and Service Provision Assessment surveys (2004, 2010) were the main sources of data. Indicators of need, use and quality for eight maternal and child health interventions were aggregated across interventions and economic quintiles to compute EC. EC has increased from 26.7% in 2003 to 50.9% in 2014, but remains low for the majority of interventions. There is a reduction in economic inequalities in EC with the highest to lowest wealth quintile ratio decreasing from 2.41 in 2003 to 1.65 in 2014, but maternal health services remain highly inequitable.ConclusionsEffective coverage of key maternal and child health services remains low, indicating that individuals are not receiving the maximum possible health gain from existing health services. There is an urgent need to focus on the quality and reach of maternal and child health services in Kenya to achieve the goals of universal health coverage.

‘You have a swelling’: The language of cancer diagnosis and implications for cancer management in Kenya

ObjectiveTo examine the ramifications of language as a vehicle of communication in the Kenyan healthcare system. Methods(1) A review of literature search on language access and health care in Kenya, using Scopus, Web of Science, Ebscohost, ProQuest and Google Scholar electronic databases. (2) Two illustrative case studies from a Nairobi based qualitative research project on family cancer caregivers’ experiences. ResultsEvidence from the case studies shows that language barriers may hinder understanding of cancer diagnoses and consequently, the nature of interventions sought by family members as informal caregivers of cancer patients. ConclusionFindings demonstrate the significance of language in understanding cancer diagnosis as a basis for treatment seeking behaviour and specifically in light of the critical role played by informal caregivers in under resourced health care contexts. Practice implications(1) The assumption that English and Swahili are adequate in communication in Kenyan health care contexts ought to be reviewed. (2) Further research and assessment of language needs as a basis for training of language interpreters in the Kenyan health care system is a necessity.

Quality management: where is the evidence? Developing an indicator-based approach in Kenya.

IntroductionThe 2030 Sustainable Development Agenda emphasizes the importance of quality of care in the drive to achieve universal health coverage. Despite recent progress, challenges in service delivery, efficiency and resource utilization in the health sector remain.ObjectiveThe Ministry of Health Department of Standards and Regulations sought to operationalize the Kenya Quality Assurance Model for Health. To this end, the European Practice Assessment (EPA) was adapted to the area of Reproductive and Maternal and Neonatal Health.MethodsThe adaptation process made use of a ten step-modified RAND Corporation/University of California Los Angeles (UCLA) Appropriateness Method. The steps included a scoping workshop, definition of five critical domains of quality in the Kenyan context (‘People, Management, Clinical Care, Quality & Safety, Interface between inpatients and outpatients care’), a review of policy documents, management and clinical guidelines, grey and scientific literature to identify indicators in use in the Kenyan health system and an expert panel process to rate their feasibility and validity.ResultsThe resulting 278 indicators, clustered across the five domains, were broken-down into 29 dimensions and assigned measure specifications. A set of data collection tools were developed to furnish the indicators and piloted at two health facilities. They were subsequently finalized for use in 30 health facilities in 3 counties.ConclusionsThe integrative and indicator-based aspects of the EPA process could be readily adapted to facilitate the operationalization of a practical quality assurance approach in Kenya.

Managerial relations in Kenyan health care: empathy and the limits of governmentality

This article describes relationships between a team of mid-level government health managers working in a rural Kenyan district and those whom they managed: health workers based at rural health facilities. In this context, managerial expertise was heavily informed by personal biography and a moral obligation to empathize with the difficult working conditions and familial responsibilities of junior staff. Management should be studied seriously in anthropology, as a powerful social and bureaucratic form. This focus must extend beyond a concern with tactics and technologies of governance to consider how modalities of managerial expertise are also shaped by biography, intersubjectivity, and professional identity.

A cross-sectional study of the availability and price of anti-malarial medicines and malaria rapid diagnostic tests in private sector retail drug outlets in rural Western Kenya, 2013.

BackgroundAlthough anti-malarial medicines are free in Kenyan public health facilities, patients often seek treatment from private sector retail drug outlets. In mid-2010, the Affordable Medicines Facility-malaria (AMFm) was introduced to make quality-assured artemisinin-based combination therapy (ACT) accessible and affordable in private and public sectors.MethodsPrivate sector retail drug outlets stocking anti-malarial medications within a surveillance area of approximately 220,000 people in a malaria perennial high-transmission area in rural western Kenya were identified via a census in September 2013. A cross-sectional study was conducted in September–October 2013 to determine availability and price of anti-malarial medicines and malaria rapid diagnostic tests (RDTs) in drug outlets. A standardized questionnaire was administered to collect drug outlet and personnel characteristics and availability and price of anti-malarials and RDTs.ResultsOf 181 drug outlets identified, 179 (99 %) participated in the survey. Thirteen percent were registered pharmacies, 25 % informal drug shops, 46 % general shops, 13 % homesteads and 2 % other. One hundred sixty-five (92 %) had at least one ACT type: 162 (91 %) had recommended first-line artemether-lumefantrine (AL), 22 (12 %) had recommended second-line dihydroartemisinin-piperaquine (DHA-PPQ), 85 (48 %) had sulfadoxine-pyrimethamine (SP), 60 (34 %) had any quinine (QN) formulation, and 14 (8 %) had amodiaquine (AQ) monotherapy. The mean price (range) of an adult treatment course for AL was $1.01 ($0.35–4.71); DHA-PPQ was $4.39 ($0.71–7.06); QN tablets were $2.24 ($0.12–4.71); SP was $0.62 ($0.24–2.35); AQ monotherapy was $0.42 ($0.24–1.06). The mean AL price with or without the AMFm logo did not differ significantly ($1.01 and 1.07, respectively; p = 0.45). Only 17 (10 %) drug outlets had RDTs; 149 (84 %) never stocked RDTs. The mean RDT price was $0.92 ($0.24–2.35).ConclusionsMost outlets never stocked RDTs; therefore, testing prior to treatment was unlikely for customers seeking treatment in the private retail sector. The recommended first-line treatment, AL, was widely available. Although SP and AQ monotherapy are not recommended for treatment, both were less expensive than AL, which might have caused preferential use by customers. Interventions that create community demand for malaria diagnostic testing prior to treatment and that increase RDT availability should be encouraged.

Opportunities and challenges for implementing cost accounting systems in the Kenyan health system

BackgroundLow- and middle-income countries need to sustain efficiency and equity in health financing on their way to universal health care coverage. However, systems meant to generate quality economic information are often deficient in such settings. We assessed the feasibility of streamlining cost accounting systems within the Kenyan health sector to illustrate the pragmatic challenges and opportunities.DesignWe reviewed policy documents, and conducted field observations and semi-structured interviews with key informants in the health sector. We used an adapted Human, Organization and Technology fit (HOT-fit) framework to analyze the components and standards of a cost accounting system.ResultsAmong the opportunities for a viable cost accounting system, we identified a supportive broad policy environment, political will, presence of a national data reporting architecture, good implementation experience with electronic medical records systems, and the availability of patient clinical and resource use data. However, several practical issues need to be considered in the design of the system, including the lack of a framework to guide the costing process, the lack of long-term investment, the lack of appropriate incentives for ground-level staff, and a risk of overburdening the current health management information system.ConclusionTo facilitate the implementation of cost accounting into the health sector, the design of any proposed system needs to remain simple and attuned to the local context.

Infection prevention and control - Bridging the knowledge gap among Kenyan health care workers

Infection prevention and control - Bridging the knowledge gap among Kenyan health care workers

Infection prevention and control – bridging the knowledge gap among Kenyan health care workers

Infection prevention and control – bridging the knowledge gap among Kenyan health care workers

Involuntary detention and compulsory treatment of non-adherent tuberculosis patients in Kenya: an ethical discourse

Tuberculosis (TB) is a major public health problem in sub-Saharan Africa due to its highly infectious nature and co-infection with HIV/AIDS. The Kenyan government has implemented various programs and strategies to control TB including the controversial jailing of patients lost to follow-up. In 2010, a Kenya court detained, in a prison facility, two TB patients who were non-adherent to treatment. A similar incidence occurred in 2016 when another TB patient who refused to adhere to TB treatment was jailed. This article analyses the ethical implications of these interventions. It is argued that jailing of patients non-adherent to TB treatment may be in contravention to the ethical principles of autonomy, justice, and equity. A central argument of this article is that incarceration not only contravenes the internationally recognized human rights to autonomy and self-determination but also predisposes the poor population to further risks of TB infection and re-infection thus depriving them of social justice and equity. The principle of the overall benefit to the society is also explored in the context of the Kenyan cases. It is further argued that mandatory isolation strategies may not only be ineffective but also inappropriate and as such, alternative isolation strategies are suggested. The need to streamline the Kenyan health system to accommodate cases of isolation is recommended.

Implementation of the Nursing Process in Naivasha District Hospital, Kenya

The Nursing Process (NP) is a systematic rational method of planning and providing individualized quality Nursing Care (QNC). Training curricula for nurses and midwives in Kenya have incorporated the NP as a framework for nursing care. In addition, many institutions in Kenya have initiated continuous education to nurses on the nursing process. However, there are no studies indicating the level of utilization of this framework in Kenyan health institutions. This study was aimed at establishing the implementation of the NP in Naivasha District Hospital. This was a cross sectional study conducted on 83 nurses and midwives selected using quota sampling. A structured questionnaire and an observation checklist was used to collect data then analyzed using the statistical package for social sciences (SPSS). Descriptive statistics were used to summarize the data and Pearson’s Correlation Coefficient was used to establish correlation between variables. The nursing process has been initiated in Naivasha District Hospital but nurses use it in an incomplete and unsystematic manner. Nurses in this hospital have a positive attitude towards the NP but have difficulties performing all the phases of the NP.

Women Who Have Sex with Women in Kenya and Their Sexual and Reproductive Health.

To describe sexual and reproductive health characteristics of women who have sex with women (WSW) in Kenya's three most populous cities: Kisumu, Mombasa, and Nairobi. Although the last decade has shown an upsurge of health-related research studies in African sexual minority populations, these studies have generally concentrated on the health status of men who have sex with men to the exclusion of WSW. This study presents the first findings on Kenyan WSW's sexual and reproductive health. A community-based, cross-sectional survey was conducted among 280 women who were at least 18 years old, had at least one female sexual partner in the past three years, and were Kenyan residents. A significant proportion of participants reported that they had at least one male sexual partner in the past three years (38.9%), ever had an abortion (13.2%), been infected with at least one sexually transmitted infection (STI) in the past three years (33.9%), and been tested for HIV at least once (88.9%). Of the women who reported having been tested for HIV, 9.4% (7.5% of the total sample) received a positive test result. Some women noted that they were open with their doctors about their sexual orientation, and that their doctors had not reacted negatively to this information. WSW in Kenya are at risk for negative sexual and reproductive health outcomes, including HIV, STIs, unplanned pregnancy, and unsafe abortion, positioning these women as a critical population for public health efforts. Some WSW actively exercise their agency in making important health decisions. Therefore, this study indicates a need to incorporate WSW's health concerns within Kenyan national health policy programming.

Motivation or demotivation of health workers providing maternal health services in rural areas in Vietnam: findings from a mixed-methods study.

BackgroundMotivation is an important driver for health professionals to maintain their professional competencies, continue in the workforce and make a positive contribution to their workplace. While there is some research about the motivation of health workers in low- to middle-income countries, maternal morbidity and mortality remains high and this can be lowered by improving the quality of maternal health services and the training and maintenance of the skills of maternal health workers. This study examines the impact of motivation on maintenance of professional competence among maternal health workers in Vietnam using mixed methods.MethodsThe study consisted of a survey using a self-administered questionnaire of 240 health workers in five districts across two Vietnamese provinces and in-depth interviews with 43 health workers and health managers at the commune, district and provincial level to explore external factors that influenced motivation. The questionnaire includes a 23-item motivation instrument based on the Kenyan health context, modified for Vietnamese language and culture.ResultsThe 240 responses represented an estimated 95% of the target sample. Multivariate analysis showed that three factors contributed to the motivation of health workers: access to training (β = −0.14, P = 0.03), ability to perform key tasks (β = 0.22, P = 0.001) and shift schedule (β = −0.13, P = 0.05). Motivation was higher in health workers self-identifying as competent or who were enabled to provide more maternal care services. Motivation was lower in those who worked more frequent night shifts and those who had received training in the last 12 months. The interviews identified that the latter was because they felt the training was irrelevant to them, and in some cases, they do not have the opportunity to practice their learnt skills. The qualitative data also showed other factors relating to service context and organisational management practices contributed to motivation.ConclusionsThe study demonstrates the importance of understanding the motivations of health workers and the factors that contribute to this and may contribute to more effective management of the health workforce in low- and middle-income countries.

Strengthening healthcare providers' skills to improve HIV services for MSM in Kenya.

Strengthening healthcare providers' skills to improve HIV services for MSM in Kenya.

Assessing the impact of a primary care electronic medical record system in three Kenyan rural health centers.

Efficient, effective health care requires rapid availability of patient information. We designed, implemented, and assessed the impact of a primary care electronic medical record (EMR) in three rural Kenyan health centers. Local clinicians identified data required for primary care and public health reporting. We designed paper encounter forms to capture these data in adult medicine, pediatric, and antenatal clinics. Encounter form data were hand-entered into a new primary care module in an existing EMR serving onsite clinics serving patients infected with the human immunodeficiency virus (HIV). Before subsequent visits, Summary Reports were printed containing selected patient data with reminders for needed HIV care. We assessed effects on patient flow and provider work with time-motion studies before implementation and two years later, and we surveyed providers' satisfaction with the EMR. Between September 2008 and December 2011, 72 635 primary care patients were registered and 114 480 encounter forms were completed. During 2011, 32 193 unique patients visited primary care clinics, and encounter forms were completed for all visits. Of 1031 (3.2%) who were HIV-infected, 85% received HIV care. Patient clinic time increased from 37 to 81 min/visit after EMR implementation in one health center and 56 to 106 min/visit in the other. However, outpatient visits to both health centers increased by 85%. Three-quarters of increased time was spent waiting. Despite nearly doubling visits, there was no change in clinical officers' work patterns, but the nurses' and the clerks' patient care time decreased after EMR implementation. Providers were generally satisfied with the EMR but desired additional training. We successfully implemented a primary care EMR in three rural Kenyan health centers. Patient waiting time was dramatically lengthened while the nurses' and the clerks' patient care time decreased. Long-term use of EMRs in such settings will require changes in culture and workflow.

Exploring the prevalence of disrespect and abuse during childbirth in Kenya.

BackgroundPoor quality of care including fear of disrespect and abuse (D&A) perpetuated by health workers influences women’s decisions to seek maternity care. Key manifestations of D&A include: physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination, abandonment, and detention in facilities. This paper describes manifestations of D&A experienced in Kenya and measures their prevalence.MethodsThis paper is based on baseline data collected during a before-and-after study designed to measure the effect of a package of interventions to reduce the prevalence of D&A experienced by women during labor and delivery in thirteen Kenyan health facilities. Data were collected through an exit survey of 641 women discharged from postnatal wards. We present percentages of D&A manifestations and odds ratios of its relationship with demographic characteristics using a multivariate fixed effects logistic regression model.ResultsTwenty percent of women reported any form of D&A. Manifestations of D&A includes: non-confidential care (8.5%), non-dignified care (18%), neglect or abandonment (14.3%), Non-consensual care (4.3%) physical abuse (4.2%) and, detainment for non-payment of fees (8.1). Women aged 20-29 years were less likely to experience non-confidential care compared to those under 19; OR: [0.6 95% CI (0.36, 0.90); p=0.017]. Clients with no companion during delivery were less likely to experience inappropriate demands for payment; OR: [0.49 (0.26, 0.95); p=0.037]; while women with higher parities were three times more likely to be detained for lack of payment and five times more likely to be bribed compared to those experiencing there first birth.ConclusionOne out of five women experienced feeling humiliated during labor and delivery. Six categories of D&A during childbirth in Kenya were reported. Understanding the prevalence of D&A is critical in developing interventions at national, health facility and community levels to address the factors and drivers that influence D&A in facilities and to encourage clients’ future facility utilization.

Health sector operational planning and budgeting processes in Kenya-"never the twain shall meet".

SummaryOperational planning is considered an important tool for translating government policies and strategic objectives into day‐to‐day management activities. However, developing countries suffer from persistent misalignment between policy, planning and budgeting. The Medium Term Expenditure Framework (MTEF) was introduced to address this misalignment. Kenya adopted the MTEF in the early 2000s, and in 2005, the Ministry of Health adopted the Annual Operational Plan process to adapt the MTEF to the health sector. This study assessed the degree to which the health sector Annual Operational Plan process in Kenya has achieved alignment between planning and budgeting at the national level, using document reviews, participant observation and key informant interviews. We found that the Kenyan health sector was far from achieving planning and budgeting alignment. Several factors contributed to this problem including weak Ministry of Health stewardship and institutionalized separation between planning and budgeting processes; a rapidly changing planning and budgeting environment; lack of reliable data to inform target setting and poor participation by key stakeholders in the process including a top‐down approach to target setting. We conclude that alignment is unlikely to be achieved without consideration of the specific institutional contexts and the power relationships between stakeholders. In particular, there is a need for institutional integration of the planning and budgeting processes into a common cycle and framework with common reporting lines and for improved data and local‐level input to inform appropriate and realistic target setting. © 2015 The Authors. International Journal of Health Planning and Management published by John Wiley & Sons, Ltd.

Association between HIV programs and quality of maternal health inputs and processes in Kenya.

We assessed whether quality of maternal and newborn health services is influenced by presence of HIV programs at Kenyan health facilities using data from a national facility survey. Facilities that provided services to prevent mother-to-child HIV transmission had better prenatal and postnatal care inputs, such as infrastructure and supplies, and those providing antiretroviral therapy had better quality of prenatal and postnatal care processes. HIV-related programs may have benefits for quality of care for related services in the health system.

Time savings--realized and potential--and fair compensation for community health workers in Kenyan health facilities: a mixed-methods approach.

BackgroundSub-Saharan Africa faces a severe health worker shortage, which community health workers (CHWs) may fill. This study describes tasks shifted from clinicians to CHWs in Kenya, places monetary valuations on CHWs’ efforts, and models effects of further task shifting on time demands of clinicians and CHWs.MethodsMixed methods were used for this study. Interviews were conducted with 28 CHWs and 19 clinicians in 17 health facilities throughout Kenya focusing on task shifting involving CHWs, time savings for clinicians as a result of task shifting, barriers and enabling factors to CHWs’ work, and appropriate CHW compensation. Twenty CHWs completed task diaries over a 14-day period to examine current CHW tasks and the amount of time spent performing them. A modeling exercise was conducted examining a current task-shifting example and another scenario in which additional task shifting to CHWs has occurred.ResultsCHWs worked an average of 5.3 hours per day and spent 36% of their time performing tasks shifted from clinicians. We estimated a monthly valuation of US$ 117 per CHW. The modeling exercise demonstrated that further task shifting would reduce the number of clinicians needed while maintaining clinic productivity by significantly increasing the number of CHWs.ConclusionsCHWs are an important component of healthcare delivery in Kenya. Our monetary estimates of current CHW contributions provide starting points for further discussion, research and planning regarding CHW compensation and programs. Additional task shifting to CHWs may further offload overworked clinicians while maintaining overall productivity.

Using Community Radios as a Tool for Development

The purpose of this study is to determine to what extent the growth of community radios have changed the lives of ordinary people in Kenya and globally; in particular the illiterate, the urban and rural poor as well as other marginalized groups. The Kenyan Demographic and Health Survey of 2003 estimated that 60% of men and 71% of women in Kenya have only gone up to the primary school level of education (Government of Kenya, 2003). Robb asserted in his study that, “I choose to focus on radio because as a technology, it is perhaps the most suitable for community media. Unlike television, it does not require extensive broadcast facilities. Nor does it necessitate the cadre of equipment or the level of capital investment that television requires. Unlike print media, community radio does not require literacy for consumption. Lastly, 99% of American homes have at least one radio, a greater percentage than read daily newspapers (55%) have personal computers (51%) or subscribe to cable television (68%) (Media Management Center, 2007). Radio remains an accessible and inexpensive form of community media”. The historical philosophy of community radios is to use this medium as the voice of the voiceless and the mouthpiece of the oppressed people, or by communities that have not been served by conventional communication structures. It should promote development at the grassroots and bring about positive change in a community's living conditions and environment through dissemination of information and promotion of community dialogue through radio debates and dialogue via phone call ins, SMS and even through social media. The thesis of this paper is that community radios are playing significant roles in livelihood improvement especially for people with no other access to mainstream media.

The green shoots of a novel training programme: progress and identified key actions to providing services to MSM at Kenyan health facilities

IntroductionAlthough men who have sex with men (MSM) in sub-Saharan Africa are at high risk for HIV acquisition, access to and quality of health and HIV services within this population are negatively affected by stigma and capacity within the health sector. A recently developed online MSM training programme (www.marps-africa.org) was shown to contribute to reductions in MSM prejudice among healthcare providers (HCPs) in coastal Kenya. In this study, we used qualitative methods to explore the provision of MSM healthcare services two years post-training in coastal Kenya.MethodsFrom February to July 2014, we held 10 focus group discussions (FGD) with 63 participants, including HCP from 25 facilities, county AIDS coordinators and MSM from local support groups. Participants discussed availability, acceptability and accessibility of HIV healthcare for MSM. HCP also discussed changes in their health service practices after completing the training. FGD were recorded, transcribed verbatim and analyzed using Ritchie and Spencer's “framework approach” for qualitative data.ResultsHCPs described continued improvements in their ability to provide service in a non-stigmatizing way to MSM patients since completing the training programme and expressed comfort engaging MSM patients in care. Four additional recommendations for improving MSM healthcare services were identified: 1) expanding the reach of MSM sensitivity training across the medical education continuum; 2) establishing guidelines to manage sexually transmitted anal infections; 3) promoting legal and policy reforms to support integration of MSM-appropriate services into healthcare; and 4) including MSM information in national reporting tools for HIV services.ConclusionsPositive impacts of this sensitivity and skills training programme were reflected in HCP attitudes two years post-intervention. Scaling-up of efforts will rely on continued policies to include MSM in healthcare programmes to reduce stigma in health settings and guidelines for MSM STI service delivery.