Newborn mortality in poor parts of the world remains unacceptably high. Basic hospital care may be an important component of attempts to save newborn lives but little is known about the capacity of such facilities to provide essential care to ill newborns.
To assess the availability of resources that support the provision of basic neonatal care in eight first-referral level (district) hospitals in Kenya.
We selected two hospitals each from four of Kenya's eight provinces with the aim of representing the diversity of this part of the health system in Kenya. We also created a checklist of 53 indicator items necessary for providing essential basic care to newborns and assessed their availability at each of the eight hospitals by direct observation. We compared our observations with the opinions of health workers providing care to newborns on recent availability for some items, using a self-administered structured questionnaire.
The hospitals surveyed were often unable to maintain a safe hygienic environment for patients and health care workers; staffing was insufficient and sometimes poorly organised to support the provision of care; some key equipment, laboratory tests, drugs and consumables were not available while patient management guidelines were missing in all sites.
Hospitals appear relatively poorly prepared to fill their proposed role in ensuring newborn survival. More effective interventions are needed to improve them to meet the special needs of this at-risk group.
It is increasingly appreciated that the interpretation of health systems research studies is greatly facilitated by detailed descriptions of study context and the process of intervention. We have undertaken an 18-month hospital-based intervention study in Kenya aiming to improve care for admitted children and newborn infants. Here we describe the baseline characteristics of the eight hospitals as environments receiving the intervention, as well as the general and local health system context and its evolution over the 18 months.
Hospital characteristics were assessed using previously developed tools assessing the broad structure, process, and outcome of health service provision for children and newborns. Major health system or policy developments over the period of the intervention at a national level were documented prospectively by monitoring government policy announcements, the media, and through informal contacts with policy makers. At the hospital level, a structured, open questionnaire was used in face-to-face meetings with senior hospital staff every six months to identify major local developments that might influence implementation. These data provide an essential background for those seeking to understand the generalisability of reports describing the intervention's effects, and whether the intervention plausibly resulted in these effects.
Hospitals had only modest capacity, in terms of infrastructure, equipment, supplies, and human resources available to provide high-quality care at baseline. For example, hospitals were lacking between 30 to 56% of items considered necessary for the provision of care to the seriously ill child or newborn. An increase in spending on hospital renovations, attempts to introduce performance contracts for health workers, and post-election violence were recorded as examples of national level factors that might influence implementation success generally. Examples of factors that might influence success locally included frequent and sometimes numerous staff changes, movements of senior departmental or administrative staff, and the presence of local 'donor' partners with alternative priorities.
The effectiveness of interventions delivered at hospital level over periods realistically required to achieve change may be influenced by a wide variety of factors at national and local levels. We have demonstrated how dynamic such contexts are, and therefore the need to consider context when interpreting an intervention's effectiveness.
We have conducted an intervention study aiming to improve hospital care for children and newborns in Kenya. In judging whether an intervention achieves its aims, an understanding of how it is delivered is essential. Here, we describe how the implementation team delivered the intervention over 18 months and provide some insight into how health workers, the primary targets of the intervention, received it.
We used two approaches. First, a description of the intervention is based on an analysis of records of training, supervisory and feedback visits to hospitals, and brief logs of key topics discussed during telephone calls with local hospital facilitators. Record keeping was established at the start of the study for this purpose with analyses conducted at the end of the intervention period. Second, we planned a qualitative study nested within the intervention project and used in-depth interviews and small group discussions to explore health worker and facilitators' perceptions of implementation. After thematic analysis of all interview data, findings were presented, discussed, and revised with the help of hospital facilitators.
Four hospitals received the full intervention including guidelines, training and two to three monthly support supervision and six monthly performance feedback visits. Supervisor visits, as well as providing an opportunity for interaction with administrators, health workers, and facilitators, were often used for impromptu, limited refresher training or orientation of new staff. The personal links that evolved with senior staff seemed to encourage local commitment to the aims of the intervention. Feedback seemed best provided as open meetings and discussions with administrators and staff. Supervision, although sometimes perceived as fault finding, helped local facilitators become the focal point of much activity including key roles in liaison, local monitoring and feedback, problem solving, and orientation of new staff to guidelines. In four control hospitals receiving a minimal intervention, local supervision and leadership to implement new guidelines, despite their official introduction, were largely absent.
The actual content of an intervention and how it is implemented and received may be critical determinants of whether it achieves its aims. We have carefully described our intervention approach to facilitate appraisal of the quantitative results of the intervention's effect on quality of care. Our findings suggest ongoing training, external supportive supervision, open feedback, and local facilitation may be valuable additions to more typical in-service training approaches, and may be feasible.
Studies on prenatal care in China have focused on the timing and frequency of prenatal care and relatively little information can be found on how maternal care has been organized and funded or on the actual content of the visits, especially in the less developed rural areas. This study explored maternal care in a rural county from Anhui province in terms of care organization, provision and utilization.
A total of 699 mothers of infants under one year of age were interviewed with structured questionnaires; the county health bureau officials and managers of township hospitals (n = 10) and county level hospitals (n = 2) were interviewed; the process of the maternal care services was observed by the researchers. In addition, statistics from the local government were used.
The county level hospitals were well staffed and equipped and served as a referral centre for women with a high-risk pregnancy. Township hospitals had, on average, 1.7 midwives serving an average population of 15,000 people. Only 10–20% of the current costs in county level hospitals and township hospitals were funded by the local government, and women paid for delivery care. There was no systematic organized prenatal care and referrals were not mandatory. About half of the women had their first prenatal visit before the 13th gestational week, 36% had fewer than 5 prenatal visits, and about 9% had no prenatal visits. A major reason for not having prenatal care visits was that women considered it unnecessary. Most women (87%) gave birth in public health facilities, and the rest in a private clinic or at home. A total of 8% of births were delivered by caesarean section. Very few women had any postnatal visits. About half of the women received the recommended number of prenatal blood pressure and haemoglobin measurements.
Delivery care was better provided than both prenatal and postnatal care in the study area. Reliance on user fees gave the hospitals an incentive to put more emphasis on revenue generating activities such as delivery care instead of prenatal and postnatal care.
Aims: To provide a comprehensive description of young infant admissions to a first referral level health facility in Kenya. These data, currently lacking, are important given present efforts to standardise their care through the integrated management of childhood illness (IMCI) and for prioritising both health care provision and disease prevention strategies.
Methods: Prospective, 18 month observational study in a Kenyan district hospital of all admissions less than 3 months of age to the paediatric ward.
Results: A total of 1080 infants were studied. Mortality was 18% overall, though in those aged 0–7 days it was 34%. Within two months of discharge a further 5% of infants aged <60 days on admission had died. Severe infection and prematurity together accounted for 57% of inpatient deaths in those aged <60 days, while jaundice and tetanus accounted for another 27%. S pneumoniae, group B streptococcus, E coli, and Klebsiella spp. were the most common causes of invasive bacterial disease. Hypoxaemia, hypoglycaemia, and an inability to feed were each present in more than 20% of infants aged 0–7 days. Both hypoxaemia and the inability to feed were associated with inpatient death (OR 3.8 (95% CI 2.5 to 5.8) and 7.4 (95% CI 4.8 to 11.2) respectively).
Conclusions: Young infants contribute substantially to paediatric inpatient mortality at the first referral level, highlighting the need both for basic supportive care facilities and improved disease prevention strategies.
Kenya like other developing countries is low in resource setting and is facing a number of challenges in the management of cervical cancer. This study documents opportunities and challenges encountered in managing cervical cancer from the health care workers’ perspectives. A qualitative study was conducted among cervical cancer managers who were defined as nurses and doctors involved in operational level management of cervical cancer. The respondents were drawn from four provincial hospitals and the only two main National public referral hospitals in Kenya. Twenty one  nurse managers and twelve  medical doctors were interviewed using a standardized interview guide. The responses were audio recorded, transcribed verbatim and the content analyzed in emerging themes.
Four themes were identified. Patient related challenges included a large number of patients, presenting in the late stage of disease, low levels of knowledge on cancer of the cervix, low levels of screening and a poor attitude towards screening procedure. Individual health care providers identified a lack of specialised training, difficulty in disclosure of diagnosis to patients, a poor attitude towards cervical cancer screening procedure and a poor attitude towards cervical cancer patients. Health facilities were lacking in infrastructure and medical supplies. Some managers felt ill-equipped in technological skills while the majority lacked access to the internet. Mobile phones were identified as having great potential for improving the management of cervical cancer in Kenya.
Kenya faces a myriad of challenges in the management of cervical cancer. The peculiar negative attitude towards screening procedure and the negative attitude of some managers towards cervical cancer patients need urgent attention. The potential use of mobile phones in cervical cancer management should be explored.
Challenges; Attitudes; Opportunities; Cervical cancer; Health care managers; Kenya
Most HIV treatment programs in resource-limited settings utilize multiple facilitators of adherence and retention in care but there is little data on the efficacy of these methods. We performed an observational cohort analysis of a treatment program in Kenya to assess which program components promote adherence and retention in HIV care in East Africa.
Patients initiating ART at A.I.C. Kijabe Hospital were prospectively enrolled in an observational study. Kijabe has an intensive program to promote adherence and retention in care during the first 6 months of ART that incorporates the following facilitators: home visits by community health workers, community based support groups, pharmacy counseling, and unannounced pill counts by clinicians. The primary endpoint was time to treatment failure, defined as a detectable HIV-1 viral load; discontinuation of ART; death; or loss to follow-up. Time to treatment failure for each facilitator was calculated using Kaplan-Meier analysis. The relative effects of the facilitators were determined by the Cox Proportional Hazards Model.
301 patients were enrolled. Time to treatment failure was longer in patients participating in support groups (448 days vs. 337 days, P<0.001), pharmacy counseling (480 days vs. 386 days, P = 0.002), pill counts (482 days vs. 189 days, P<0.001) and home visits (485 days vs. 426 days, P = 0.024). Better adherence was seen with support groups (89% vs. 82%, P = 0.05) and pill counts (89% vs. 75%, P = 0.02). Multivariate analysis using the Cox Model found significant reductions in risk of treatment failure associated with pill counts (HR = 0.19, P<0.001) and support groups (HR = 0.43, P = 0.003).
Unannounced pill counts by the clinician and community based support groups were associated with better long term treatment success and with better adherence.
Kenya, like many other countries in sub-Saharan Africa, has been affected by shortages of health workers in the public sector. Data on the rates and leading reasons for health workers attrition in the public sector are key in developing effective, evidence-based planning and policy on human resources for health.
This study analysed data from a human resources health facility survey conducted in 2005 in 52 health centres and 22 public hospitals (including all provincial hospitals) across all eight provinces in Kenya. The study looked into the status of attrition rates and the proportion of attrition due to retirement, resignation or death among doctors, clinical officers, nurses and laboratory and pharmacy specialists in surveyed facilities.
Overall health workers attrition rates from 2004 to 2005 were similar across type of health facility: provincial hospitals lost on average 4% of their health workers, compared to 3% for district hospitals and 5% for health centres. However, there are differences in the patterns of attrition rates by cadre. Attrition among doctors and registered nurses was much higher at the provincial hospitals than at district hospitals or health centres, whereas the opposite pattern was observed for laboratory and pharmacy staff (lost at a higher rate in lower-level facilities). In provincial hospitals, doctors had higher attrition rates than clinical officers, and registered nurses had higher attrition rates than enrolled nurses. In contrast, attrition of enrolled and registered nurses in district hospitals and health centres was similar. The main reason for health worker attrition (all cadres combined) at each level of facility was retirement, followed by resignation and death. However, resignation drives attrition among doctors and clinical officers; retirement accounts for the main share of attrition among nurses and pharmacy staff; and death is the primary reason for attrition among laboratory staff, particularly in district hospitals. One limitation of the data is that sampling of health centres was non-random and the results may thus not be representative of all health centres.
Our findings indicate that appropriate policies to retain staff in the public health sector may need to be tailored for different cadres and level of health facility. Further studies, perhaps employing qualitative research, need to investigate the importance of different factors in the decision of health workers to resign.
The primary objective was to evaluate the capacity of first-referral health facilities in Tanzania to perform basic surgical procedures. The intent was to assist in planning strategies for universal access to life-saving and disability-preventing surgical services.
First-referral health facilities in the United Republic of Tanzania.
48 health facilities.
The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was employed to capture a health facility's capacity to perform basic surgical (including obstetrics and trauma) and anaesthesia interventions by investigating four categories of data: infrastructure, human resources, interventions available and equipment. The tool queried the availability of eight types of care providers, 35 surgical interventions and 67 items of equipment.
The 48 facilities surveyed served 18.6 million residents (46% of the population). Supplies for basic airway management were inconsistently available. Only 42% had consistent access to oxygen, and only six functioning pulse oximeters were located in all facilities surveyed. 37.5% of facilities reported both consistent running water and electricity. While very basic interventions (suturing, wound debridement, incision and drainage) were provided in nearly all facilities, more advanced life-saving procedures including chest tube thoracostomy (30/48), open fracture management (29/48) and caesarean section delivery (32/48) were not consistently available.
Based on the results in this WHO country survey, significant gaps exist in the capacity for emergency and essential surgical services in Tanzania including deficits in human resources, essential equipment and infrastructure. The information in this survey will provide a foundation for evidence-based decisions in country-level policy regarding the allocation of resources and provision of emergency and essential surgical services.
On-site visits to primary health centres in a developing nation.
Evaluate capacity to deliver emergency and surgical care-identify gaps in equipment, skills and personnel.
Basic surgical procedures are being performed in nearly all health centres.
Significant deficits in human resources, essential equipment and infrastructure.
Pulse oximetry is rarely available.
Strengths and limitations of this study
Most comprehensive evaluation of a developing country's surgical capacity.
Based on established well-accepted analysis tool.
Relies on subjective measures and estimate.
The aim of the adoption process of the “Quality of hospital care for mothers and newborns babies, assessment tool” (WHO, 2009) was to provide the Albanian health professionals of maternity hospitals with a tool that may help them assess the quality of perinatal care and identify key areas of pregnancy, childbirth and newborn care that need to be improved.
Four maternity hospitals (one university hospital and three regional hospitals) were selected for the assessment using this standard tool covering over 600 items grouped into 13 areas ranging from supportive services to case management. Sources of information consisted of site visits, hospital statistics, medical records, observation of cases and interviews with staff and patients. A score was assigned to each item (range 0-3) and area of care. The assessments were carried out in two rounds: in 2009 and in 2011. These assessments provided semi-quantitative data on the quality of hospital care for mothers and newborns.
Data collected on the first round established a baseline assessment, whereas the second round monitored the subsequent changes. The findings of the second round revealed improvements encountered in all maternities, notwithstanding differences in the levels of improvement between maternities, not necessarily linked with extra financial inputs.
The Albanian experience indicates a successful process of the adoption of the WHO tool on the quality of hospital care for mothers and newborn babies. The adopted tool can be used country-wide as a component of a quality improvement strategy in perinatal health care in Albania.
Albania; maternity hospital; quality; WHO assessment tool.
The Projahnmo-II Project in Mirzapur upazila (sub-district), Tangail district, Bangladesh, is promoting care-seeking for sick newborns through health education of families, identification and referral of sick newborns in the community by community health workers (CHWs), and strengthening of neonatal care in Kumudini Hospital, Mirzapur. Data were drawn from records maintained by the CHWs, referral hospital registers, a baseline household survey of recently-delivered women conducted from March to June 2003, and two interim household surveys in January and September 2005. Increases were observed in self-referral of sick newborns for care, compliance after referral by the CHWs, and care-seeking from qualified providers and from the Kumudini Hospital, and decreases were observed in care-seeking from unqualified providers in the intervention arm. An active surveillance for illness by the CHWs in the home, education of families by them on recognition of danger signs and counselling to seek immediate care for serious illness, and improved linkages between the community and the hospital can produce substantial increases in care-seeking for sick newborns.
Delivery of healthcare; Health services; Care-seeking; Referral and consultation; Community health workers; Neonatal health; Maternal health; Bangladesh
To explore the impact of HIV/AIDS on maternity care providers (MCP) in labor and delivery in a high HIV prevalence setting in sub-Saharan Africa.
Qualitative one-on-one in-depth interviews with MCPs.
Four health facilities providing labor and delivery services (2 public hospitals, a public health center, and a small private maternity hospital) in Kisumu, Nyanza Province, Kenya.
Eighteen (18) MCPs, including 14 nurse/midwives, 2 physician assistants, and 2 physicians (ob/gyn specialists).
The HIV/AIDS epidemic has had numerous adverse effects and a few positive effects on MCPs in this setting. Adverse effects include reductions in the number of health care providers, increased workload, burnout, reduced availability of services in small health facilities when workers are absent due to attending HIV/AIDS training programs, difficulties with confidentiality and unwanted disclosure, and MCPs' fears of becoming HIV infected and the resulting stigma and discrimination. Positive effects include improved infection control procedures on maternity wards and enhanced MCP knowledge and skills.
A multi-faceted package including policy, infrastructure, and training interventions is needed to support MCPs in these settings and ensure that they are able to perform their critical roles in maternal healthcare and prevention of HIV/AIDS transmission.
HIV/AIDS; maternity care providers; safe motherhood; Kenya
More than 70% of children with sickle cell disease (SCD) are born in sub-Saharan Africa where the prevalence at birth of this disease reaches 2% or higher in some selected areas. There is a dearth of knowledge on comprehensive care received by children with SCD in sub-Saharan Africa and its associated cost. Such knowledge is important for setting prevention and treatment priorities at national and international levels. This study focuses on routine care for children with SCD in an outpatient clinic of the Kilifi District Hospital, located in a rural area on the coast of Kenya.
To estimate the per-patient costs for routine SCD outpatient care at a rural Kenyan hospital.
We collected routine administrative and primary cost data from the SCD outpatient clinic and supporting departments at Kilifi District Hospital, Kenya. Costs were estimated by evaluating inputs - equipment, medication, supplies, building use, utility, and personnel - to reflect the cost of offering this service within an existing healthcare facility. Annual economic costs were similarly calculated based on input costs, prorated lifetime of equipment and appropriate discount rate. Sensitivity analyses evaluated these costs under different pay scales and different discount rate.
We estimated that the annual economic cost per patient attending the SCD clinic was USD 138 in 2010 with a range of USD 94 to USD 229.
This study supplies the first published estimate of the cost of routine outpatient care for children born with SCD in sub-Saharan Africa. Our study provides policy makers with an indication of the potential future costs of maintaining specialist outpatient clinics for children living with SCD in similar contexts.
Birth asphyxia kills 0.7 to 1.6 million newborns a year globally with 99% of deaths in developing countries. Effective newborn resuscitation could reduce this burden of disease but the training of health-care providers in low income settings is often outdated. Our aim was to determine if a simple one day newborn resuscitation training (NRT) alters health worker resuscitation practices in a public hospital setting in Kenya.
We conducted a randomised, controlled trial with health workers receiving early training with NRT (n = 28) or late training (the control group, n = 55). The training was adapted locally from the approach of the UK Resuscitation Council. The primary outcome was the proportion of appropriate initial resuscitation steps with the frequency of inappropriate practices as a secondary outcome. Data were collected on 97 and 115 resuscitation episodes over 7 weeks after early training in the intervention and control groups respectively. Trained providers demonstrated a higher proportion of adequate initial resuscitation steps compared to the control group (trained 66% vs control 27%; risk ratio 2.45, [95% CI 1.75–3.42], p<0.001, adjusted for clustering). In addition, there was a statistically significant reduction in the frequency of inappropriate and potentially harmful practices per resuscitation in the trained group (trained 0.53 vs control 0.92; mean difference 0.40, [95% CI 0.13–0.66], p = 0.004).
Implementation of a simple, one day newborn resuscitation training can be followed immediately by significant improvement in health workers' practices. However, evidence of the effects on long term performance or clinical outcomes can only be established by larger cluster randomised trials.
Prolonged exposure to war has severely impacted the provision of health services in the Democratic Republic of the Congo (DRC). Health infrastructure has been destroyed, health workers have fled and government support to health care services has been made difficult by ongoing conflict. Poor reproductive health (RH) indicators illustrate the effect that the prolonged crisis in DRC has had on the on the reproductive health (RH) of Congolese women. In 2007, with support from the RAISE Initiative, the International Rescue Committee (IRC) and CARE conducted baseline assessments of public hospitals to evaluate their capacities to meet the RH needs of the local populations and to determine availability, utilization and quality of RH services including emergency obstetric care (EmOC) and family planning (FP).
Data were collected from facility assessments at nine general referral hospitals in five provinces in the DRC during March, April and November 2007. Interviews, observation and clinical record review were used to assess the general infrastructure, EmOC and FP services provided, and the infection prevention environment in each of the facilities.
None of the nine hospitals met the criteria for classification as an EmOC facility (either basic or comprehensive). Most facilities lacked any FP services. Shortage of trained staff, essential supplies and medicines and poor infection prevention practices were consistently documented. All facilities had poor systems for routine monitoring of RH services, especially with regard to EmOC.
Women's lives can be saved and their well-being improved with functioning RH services. As the DRC stabilizes, IRC and CARE in partnership with the local Ministry of Health and other service provision partners are improving RH services by: 1) providing necessary equipment and renovations to health facilities; 2) improving supply management systems; 3) providing comprehensive competency-based training for health providers in RH and infection prevention; 4) improving referral systems to the hospitals; 5) advocating for changes in national RH policies and protocols; and 6) providing technical assistance for monitoring and evaluation of key RH indicators. Together, these initiatives will improve the quality and accessibility of RH services in the DRC - services which are urgently needed and to which Congolese women are entitled by international human rights law.
After almost 10 years of PEPFAR funding for antiretroviral therapy (ART) treatment programmes in Kenya, little is known about the cost of care provided to HIV-positive patients receiving ART. With some 430,000 ART patients, understanding and managing costs is essential to treatment programme sustainability.
Using patient-level data from medical records (n=120/site), we estimated the cost of providing ART at three treatment sites in the Rift Valley Province of Kenya (a clinic at a government hospital, a hospital run by a large agricultural company and a mission hospital). Costs included ARV and non-ARV drugs, laboratory tests, salaries to personnel providing patient care, and infrastructure and other fixed costs. We report the average cost per patient during the first 12 months after ART initiation, stratified by site, and the average cost per patient achieving the primary outcome, retention in care 12 months after treatment initiation.
The cost per patient initiated on ART was $206, $252 and $213 at Sites 1, 2 and 3, respectively. The proportion of patients remaining in care at 12 months was similar across all sites (0.82, 0.80 and 0.84). Average costs for the subset of patients who remained in care at 12 months was also similar (Site 1, $229; Site 2, $287; Site 3, $237). Patients not retained in care cost substantially less (Site 1, $104; Site 2, $113; Site 3, $88). For the subset of patients who remained in care at 12 months, ART medications accounted for 51%, 44% and 50% of the costs, with the remaining costs split between non-ART medications (15%, 11%, 10%), laboratory tests (14%, 15%, 15%), salaries to personnel providing patient care (9%, 11%, 12%) and fixed costs (11%, 18%, 13%).
At all three sites, 12-month retention in care compared favourably to retention rates reported in the literature from other low-income African countries. The cost of providing treatment was very low, averaging $224 in the first year, less than $20/month. The cost of antiretroviral medications, roughly $120 per year, accounted for approximately half of the total costs per patient retained in care after 12 months.
HIV; Kenya; antiretroviral therapy; cost analysis; retent
The implementation and utilization of programmes for the prevention of mother-to-child transmission (PMTCT) of HIV in most low income countries has been described as sub-optimal. As planners and service providers, the views of health workers are important in generating priorities to improve the effectiveness of the PMTCT programme in Uganda. We explored the lessons learnt by health workers involved in the provision of PMTCT services in eastern Uganda to better understand what more needs to be done to strengthen the PMTCT programme.
A qualitative study was conducted at Mbale Regional Referral Hospital, The AIDS Support Organisation (TASO) Mbale and at eight neighbouring health centres in eastern Uganda, between January and May 2010. Data were collected through 24 individual interviews with the health workers involved in the PMTCT programme and four key informants (2 district officials and 2 officials from TASO). Data were analyzed using the content thematic approach. Study themes and sub-themes were identified following multiple reading of interview transcripts. Relevant quotations have been used in the presentation of study findings.
The key lessons for programme improvement were: ensuring constant availability of critical PMTCT supplies, such as HIV testing kits, antiretroviral drugs (ARVs) for mothers and their babies, regular in-service training of health workers to keep them abreast with the rapidly changing knowledge and guidelines for PMTCT, ensuring that lower level health centres provide maternity services and ARVs for women in the PMTCT programme and provision of adequate facilities for effective follow-up and support for mothers.
The voices of health workers in this study revealed that it is imperative for government, civil society organizations and donors that the PMTCT programme addresses the challenges of shortage of critical PMTCT supplies, continuous health worker training and follow-up and support for mothers as urgent needs to strengthen the PMTCT programme.
To assess the structural capacity for, and quality of, immediate and essential newborn care (ENC) in health facilities in rural Ghana, and to link this with demand for facility deliveries and admissions.
Health facility assessment survey and population-based surveillance data.
Seven districts in Brong Ahafo Region, Ghana.
Heads of maternal/neonatal wards in all 64 facilities performing deliveries.
Main outcome measures
Indicators include: the availability of essential infrastructure, newborn equipment and drugs, and personnel; vignette scores and adequacy of reasons given for delayed discharge of newborn babies; and prevalence of key immediate ENC practices that facilities should promote. These are matched to the percentage of babies delivered in and admitted to each type of facility.
70% of babies were delivered in health facilities; 56% of these and 87% of neonatal admissions were in four referral level hospitals. These had adequate infrastructure, but all lacked staff trained in ENC and some essential equipment (including incubators and bag and masks) and/or drugs. Vignette scores for care of very low-birth-weight babies were generally moderate-to-high, but only three hospitals achieved high overall scores for quality of ENC. We estimate that only 33% of babies were born in facilities capable of providing high quality, basic resuscitation as assessed by a vignette plus the presence of a bag and mask. Promotion of immediate ENC practices in facilities was also inadequate, with coverage of early initiation of breastfeeding and delayed bathing both below 50% for babies born in facilities; this represents a lost opportunity.
Unless major gaps in ENC equipment, drugs, staff, practices and skills are addressed, strategies to increase facility utilisation will not achieve their potential to save newborn lives.
Epidemiology; Neonatology; Public health
To describe out-of-pocket costs of inpatient care for children under 5 years of age in district hospitals in Kenya.
A total of 256 caretakers of admitted children were interviewed in 2-week surveys conducted in eight hospitals in four provinces in Kenya. Caretakers were asked to report care seeking behaviour and expenditure related to accessing inpatient care. Family socio-economic status was assessed through reported expenditure in the previous month.
Seventy eight percent of caretakers were required to pay user charges to access inpatient care for children. User charges (mean, US$ 8.1; 95% CI, 6.4–9.7) were 59% of total out-of-pocket costs, while transport costs (mean, US$ 4.9; 95% CI, 3.9–6.0) and medicine costs (mean, US$ 0.7; 95% CI, 0.5–1.0) were 36% and 5%, respectively. The mean total out-of-pocket cost per paediatric admission was US$ 14.1 (95% CI, 11.9–16.2). Out-of-pocket expenditures on health were catastrophic for 25.4% (95% CI, 18.4–33.3) of caretakers interviewed. Out-of-pocket expenditures were regressive, with a greater burden being experienced by households with lower socio-economic status.
Despite a policy of user fee exemption for children under 5 years of age in Kenya, our findings show that high unofficial user fees are still charged in district hospitals. Financing mechanisms that will offer financial risk protection to children seeking care need to be developed to remove barriers to child survival.
user fees; out-of-pocket costs; child health; hospitals
We wanted to try to account for worker motivation as a key factor that might affect the success of an intervention to improve implementation of health worker practices in eight district hospitals in Kenya. In the absence of available tools, we therefore aimed to develop a tool that could enable a rapid measurement of motivation at baseline and at subsequent points during the 18-month intervention study.
After a literature review, a self-administered questionnaire was developed to assess the outcomes and determinants of motivation of Kenyan government hospital staff. The initial questionnaire included 23 questions (from seven underlying constructs) related to motivational outcomes that were then used to construct a simpler tool to measure motivation. Parallel qualitative work was undertaken to assess the relevance of the questions chosen and the face validity of the tool.
Six hundred eighty-four health workers completed the questionnaires at baseline. Reliability analysis and factor analysis were used to produce the simplified motivational index, which consisted of 10 equally-weighted items from three underlying factors. Scores on the 10-item index were closely correlated with scores for the 23-item index, indicating that in future rapid assessments might be based on the 10 questions alone. The 10-item motivation index was also able to identify statistically significant differences in mean health worker motivation scores between the study hospitals (p < 0.001). The parallel qualitative work in general supported these conclusions and contributed to our understanding of the three identified components of motivation.
The 10-item score developed may be useful to monitor changes in motivation over time within our study or be used for more extensive rapid assessments of health worker motivation in Kenya.
The purpose of this study was to assess postoperative complications and patient satisfaction associated with mid-level provision of male circumcision in rural Kenya.
A prospective cohort study was conducted among children, adolescents, and adult men undergoing male circumcision from September 1, 2008 to December 4, 2008 at Marie Stopes International Kenya mobile outreach sites located in eight districts in the Nyanza and Western Provinces, Kenya. Male circumcision procedures were performed by registered nurses, surgical technicians, or nurse aides. Postoperative follow-up visits took place on the day of the procedure and at postoperative days 3, 7, and 30, with additional visits as necessary. Data on adverse events, healing conditions, satisfaction level, and resumption of activities were assessed at each follow-up visit.
A total of 285 individuals were screened, and 240 underwent male circumcision procedures. All procedures were performed using the guided forceps technique by mid-level providers. At the first follow-up visit (postoperative day 3), 5.8% (n = 14) individuals did not return for post-surgical assessment. Retention rates at the second (day 7) and third (day 30) follow-up visits were 91.3% (n = 219) and 84.6% (n = 203), respectively. The prevalence of complications (moderate and severe adverse events) was 1.3% (3/240). At the first and second follow-up visits, 91.7% of patients (n = 220) were capable of resuming their daily activities, and 100% by day 30. The majority of patients (>99%) were satisfied with the procedure, counseling, and information received.
Male circumcisions can be delivered safely and successfully by mid-level providers in rural settings with high client satisfaction, thereby increasing access to human immunodeficiency virus prevention services in Kenya.
male circumcision; human immunodeficiency virus; reproductive health; mid-level providers; Kenya
Congenital malaria is defined as malaria parasitaemia in the first week of life. The reported prevalence of congenital malaria in sub-Saharan Africa is variable (0 - 46%). Even though the clinical significance of congenital malaria parasitaemia is uncertain, anti-malarial drugs are empirically prescribed for sick newborns by frontline health care workers. Data on prevalence of congenital malaria in high-risk newborns will inform appropriate drug use and timely referral of sick newborns.
Blood samples of untreated newborns less than 1 week of age at the time of referral to Korle Bu Teaching hospital in Accra, Ghana during the peak malaria seasons (April to July) of 2008 and 2010 were examined for malaria parasites by, i) Giemsa-stained thick and thin blood smears for parasite count and species identification, ii) histidine-rich protein- and lactic dehydrogenase-based rapid diagnosis tests, or iii) polymerase chain reaction amplification of the merozoite surface protein 2 gene, for identification of sub-microscopic parasitaemia. Other investigations were also done as clinically indicated.
In 2008, nine cases of Plasmodium falciparum parasitaemia were diagnosed by microscopy in 405 (2.2%) newborns. All the nine newborns had low parasite densities (≤50 per microlitre). In 2010, there was no case of parasitaemia by either microscopy or rapid diagnosis tests in 522 newborns; however, 56/467 (12%) cases of P. falciparum were detected by polymerase chain reaction.
Congenital malaria is an uncommon cause of clinical illness in high-risk untreated newborns referred to a tertiary hospital in the first week of life. Empirical anti-malarial drug treatment for sick newborns without laboratory confirmation of parasitaemia is imprudent. Early referral of sick newborns to hospitals with resources and skills for appropriate care is recommended.
Congenital; Malaria; Newborn; Ghana
The neonatal mortality rate in India is high and stagnant. Special Care Newborn Units (SCNUs) have been set up to provide quality level II newborn-care services in several district hospitals to meet this challenge. The units are located in some remotest districts where the burden of neonatal deaths is high, and access to special newborn care is poor. The study was conducted to assess the functioning of SCNUs in eight rural districts of India. The evaluation was based on an analysis of secondary data from the eight units that had been functioning for at least one year. A cross-sectional survey was also conducted to assess the availability of human resources, equipment, and quality care. Descriptive statistics were used for analyzing the inputs (resources) and outcomes (morbidity and mortality). The rate of mortality among admitted neonates was taken as the key outcome variable to assess the performance of the units. Chi-square test was used for analyzing the trend of case-fatality rate over a period of 3-5 years considering the first year of operationalization as the base. Correlation coefficients were estimated to understand the possible association of case-fatality rate with factors, such as bed:doctor ratio, bed:nurse ratio, average duration of stay, and bed occupancy rate, and the asepsis score was determined. The rates of admission increased from a median of 16.7 per 100 deliveries in 2008 to 19.5 per 100 deliveries in 2009. The case-fatality rate reduced from 4% to 40% within one year of their functioning. Proportional mortality due to sepsis and low birthweight (LBW) declined significantly over two years (LBW <2.5 kg). The major reasons for admission and the major causes of deaths were birth asphyxia, sepsis, and LBW/prematurity. The units had a varying nurse:bed ratio (1:0.5-1:1.3). The bed occupancy rate ranged from 28% to 155% (median 103%), and the average duration of stay ranged from two days to 15 days (median 4.75 days). Repair and maintenance of equipment were a major concern. It is possible to set up and manage quality SCNUs and improve the survival of newborns with LBW and sepsis in developing countries, although several challenges relating to human resources, maintenance of equipment, and maintenance of asepsis remain.
Cross-sectional studies; Neonatal mortality; Newborn care; Performance evaluation; India
The change of malaria case-management policy in Kenya to recommend universal parasitological diagnosis and targeted treatment with artemether-lumefantrine (AL) is supported with activities aiming by 2013 at universal coverage and adherence to the recommendations. We evaluated changes in health systems and case-management indicators between the baseline survey undertaken before implementation of the policy and the follow-up survey following the first year of the implementation activities.
National, cross-sectional surveys using quality-of-care methods were undertaken at public facilities. Baseline and follow-up surveys respectively included 174 and 176 facilities, 224 and 237 health workers, and 2,405 and 1,456 febrile patients. Health systems indicators showed variable changes between surveys: AL stock-out (27% to 21%; p = 0.152); availability of diagnostics (55% to 58%; p = 0.600); training on the new policy (0 to 22%; p = 0.001); exposure to supervision (18% to 13%; p = 0.156) and access to guidelines (0 to 6%; p = 0.001). At all facilities, there was an increase among patients tested for malaria (24% vs 31%; p = 0.090) and those who were both tested and treated according to test result (16% to 22%; p = 0.048). At facilities with AL and malaria diagnostics, testing increased from 43% to 50% (p = 0.196) while patients who were both, tested and treated according to test result, increased from 28% to 36% (p = 0.114). Treatment adherence improved for test positive patients from 83% to 90% (p = 0.150) and for test negative patients from 47% to 56% (p = 0.227). No association was found between testing and exposure to training, supervision and guidelines, however, testing was significantly associated with facility ownership, type of testing, and patients' caseload, age and clinical presentation.
Most of the case-management indicators have shown some improvement trends; however differences were smaller than expected, rarely statistically significant and still leaving a substantial gap towards optimistic targets. The quantitative and qualitative improvement of interventions will ultimately determine the success of the new policy.
In Nyanza Province, Kenya, estimated HIV prevalence is 22%. Given that more than 80% of the population resides in rural areas, the majority of individuals in Nyanza Province do not have access to medical facilities on a regular basis. In response to the growing demands the HIV epidemic has placed on the people and communities in this region, hundreds of lay individuals have been trained as community health workers to provide home-based care to sick or dying HIV/AIDS clients in rural areas. This paper discusses the role and impact of these community health workers in Nyanza Province, Kenya. It outlines the collaborative relationship between community health workers and the Ministry of Health, examining community health workers' use of extant biomedical structures at the district level to provide services that government-run health facilities lack the monetary resources or personnel to provide. Finally, it explores the role played by community health workers in providing HIV/AIDS education to individuals in an attempt to prevent further infections.