Dan Kaseje

Growth of civil society in developing countries: implications for health

Owing to changes in political systems, the number of non-governmental organisations worldwide has increased substantially since 1980. The influence of civil society on health and health care depends on the recognition of its role as a partner in primary health care, on its success in the scaling up of activities, on its cooperation with the State and business sector, and on networking. In the event of health-sector reforms, civil society should focus on equity and justice, and advocate health as a public responsibility. The impact on health would increase if medical personnel joined forces with civil society and if medical schools added public speaking, networking, and lobbying to their agenda. The trend is that an increasing number of agents are getting involved in the promotion of health.

A quasi-experimental assessment of the effectiveness of the Community Health Strategy on health outcomes in Kenya

BackgroundDespite focused health policies and reform agenda, Kenya has challenges in improving households’ situation in poverty and ill health; interventions to address the Millennium Development Goals in maternal and child health, such as focused antenatal care and immunization of children, are yet to achieve success. Research has shown that addressing the demand side is critical in improving health outcomes. This paper presents a model for health systems performance improvement using a strategy that bridges the interface between the community and the health system.MethodsThe study employed quasi-experimental design, using pre- and post-intervention surveys in intervention and control sites. The intervention was the implementation of all components of the Kenyan Community Health Strategy, guided by policy. The two year intervention (2011 and 2012) saw the strategy introduced to selected district health management teams, service providers, and communities through a series of three-day training workshops that were held three times during the intervention period.Baseline and endline surveys were conducted in intervention and control sites where community unit assessment was undertaken to determine the status of health service utilization before and after the intervention. A community health unit consists of 1000 households, a population of about 5000, served by trained community health workers, each supporting about 20 to 50 households. Data was organized and analyzed using Excel, SPSS, Epi info, Stata Cal, and SAS.ResultsA number of health indicators, such as health facility delivery, antenatal care, water treatment, latrine use, and insecticide treated nets, improved in the intervention sites compared to non-interventions sites. The difference between intervention and control sites was statistically significant (p<0.0001) for antenatal care, health facility delivery, water treatment, latrine use, use of insecticide treated nets, presence of clinic card, and measles vaccination. Degree of improvement across the various indicators measured differed by socio-demographic contexts. The changes were greatest in the rural agrarian sites, compared to peri-urban and nomadic sites.ConclusionThe study showed that most of the components of the strategy were implemented and sustained in different socio-demographic contexts, while participatory community planning based on household information drives improvement of health indicators.RésuméContexteMalgré des politiques de santé ciblées et un programme de réformes, le Kenya éprouve de la difficulté à améliorer la situation économique et sanitaire des ménages. Les interventions menées pour atteindre les objectifs du Millénaire pour le développement en matière de santé maternelle et infantile, comme des soins prénataux ciblés et la vaccination des enfants, n’ont pas encore donné les résultats escomptés. La recherche a révélé que, pour améliorer l’état de santé, il est crucial de prendre en compte la demande. Notre article présente un modèle d’amélioration du rendement des systèmes de santé fondé sur une stratégie qui relie les systèmes de santé communautaire et institutionnel.MéthodesL’étude repose sur une conception quasi expérimentale qui comprend des enquêtes réalisées avant et après l’intervention dans des sites sujets et témoins. L’intervention consistait à mettre en oeuvre toutes les composantes de la stratégie en santé communautaire du Kenya, en suivant des politiques. L’intervention a été lancée au sein de certains fournisseurs de services, équipes de gestion et collectivités et a pris la forme d’une série d’ateliers de formation s’étalant sur trois jours tenus trois fois pendant les deux années qu’a duré l’intervention (2011 et 2012).Les enquêtes réalisées avant et après l’intervention ont été menées dans les sites sujets et témoins. On a effectué une évaluation de l’unité de santé communautaire pour déterminer le taux d’utilisation des services de santé avant et après l’intervention. Une unité de santé communautaire est constituée de 1 000 ménages, soit environ 5 000 personnes, servis par des travailleurs en santé communautaire formés qui travaillent auprès de 20 à 50 ménages chacun. Les données ont été organisées et analysées au moyen de divers outils : Excel, SPPS, Epi info, Stata Cal et SAS.RésultatsCertains indicateurs de santé se sont améliorés dans les sites sujets, comme la prestation de services dans les établissements de santé, les soins prénataux, le traitement de l’eau, l’utilisation des latrines et de moustiquaires traitées aux insecticides. En ce qui a trait aux soins prénataux, à la prestation de services dans les établissements de santé, au traitement de l’eau, à l’utilisation des latrines et de moustiquaires traitées aux insecticides, à la présence de cartes de clinique et à la vaccination contre la rougeole, la différence observée entre les sites sujets et les sites témoins était considérable sur le plan statistique (<0.0001). Le taux d’amélioration des différents indicateurs mesurés variait en fonction du contexte sociodémographique. Les indicateurs fluctuaient davantage dans les milieux ruraux agricoles que dans les milieux périurbains ou nomades.ConclusionL’étude a montré que la plupart des composantes de la stratégie ont été mises en oeuvre et maintenues dans différents contextes sociodémographiques, et la planification communautaire participative fondée sur les données sur les ménages améliore la santé globale.

Validity and reliability of data collected by community health workers in rural and peri-urban contexts in Kenya

BackgroundReliability and validity of measurements are important for the interpretation and generalisation of research findings. Valid, reliable and comparable measures of health status of individuals are critical components of the evidence base for health policy. The need for sound information is especially urgent in the case of emerging diseases and other acute health threats, where rapid awareness, investigation and response can save lives and prevent broader national outbreaks and even global pandemics.Several successfully implemented health interventions have involved community health workers (CHWs) in reaching out to the community, and the Community Health Strategy is one such an intervention. The government of Kenya, through the Ministry of Public Health and Sanitation has rolled out the strategy as a way of improving health care at the household level. It involves CHWs collecting health status data at the household level, which is presented at community meetings in which the community discusses the results, identifies action areas, and plans activities for improving their health status.MethodsTen percent of all households visited by CHWs for data collection in different sites (rural and peri-urban) were systematically selected and visited a second time by technically trained research team members. The test-retest method was applied to establish reliability. The Kappa score was used to measure reliability, while sensitivity, specificity, and positive predictive values were used to measure validity.ResultsInter-observer agreement between the two sets of data in both sites was good; most indicators measured slight agreement. However, some indicators demonstrated greater discrepancies between the two data sets (e.g. measles immunization). Specificity measures were more stable in Butere (rural), which had more than 90% in all the indicators tested, compared to Nyalenda (peri-urban), which fluctuated between 50% and 90%. There were variable reliability results in the peri-urban site for the indicators measured, while the rural site presented more stable results. This is also depicted in the validity measures in both sites.ConclusionsThe paper concludes that there are convincing results that CHWs can accurately and reliably collect certain types of community data which has cost-saving implications, especially for resource poor settings.RésuméContexteLa validité et la fiabilité des mesures sont importantes pour l’interprétation et la généralisation des résultats de recherche. Des mesures valables, fiables et comparables de l’état de santé des individus sont une partie importante de la base de données probantes pour les politiques en matière de santé. Le besoin d’information fiable est particulièrement criant dans le cas des maladies émergentes et d’autres risques sanitaires graves, où une prise de conscience, une enquête et une intervention rapides peuvent sauver des vies et prévenir les épidémies nationales et même des pandémies mondiales.Plusieurs interventions en santé réussies ont comporté un déploiement d’agents de santé communautaire (ASC) dans les collectivités; la stratégie en santé communautaire est l’une de ces interventions. Le gouvernement du Kenya, par le truchement du ministère de la Santé publique et de la Salubrité, a mis en oeuvre cette stratégie dans le but d’améliorer les soins de santé pour les ménages. Pour ce faire, il est nécessaire que les ASC recueillent des données sur l’état de santé des ménages, qui sont alors présentées dans le cadre de rencontres communautaires où l’on discute des résultats, détermine des champs d’action et planifie des actions afin d’améliorer leur état de santé.MéthodesDix pour cent de tous les ménages visités par les ASC pour la cueillette de données dans différents milieux (ruraux et périurbains) ont été systématiquement rencontrés une deuxième fois par des membres de l’équipe de recherche ayant reçu une formation technique. La méthode du test-retest a été appliquée pour établir la fiabilité. L’indice Kappa a été utilisé pour mesurer la fiabilité, alors que la sensibilité, la précision et la valeur prédictive positive ont été calculées pour mesurer la validité.RésultatsL’accord entre les données des deux ensembles d’observateurs dans les deux milieux était bon, la plupart des indicateurs possédaient un accord faible. Toutefois, certains indicateurs montraient de plus grands écarts entre les deux ensembles de données (p. ex., la vaccination contre la rougeole). Les mesures de spécificité étaient plus stables dans le district de Butere (milieu rural) qui a obtenu plus de 90 % dans tous les indicateurs testés, comparativement à Nyalenda (périurbain) où les résultats fluctuaient de 50 % à 90 %. Les résultats concernant la fiabilité étaient variables dans les milieux périurbains pour les indicateurs mesurés, alors que les milieux ruraux présentaient des résultats plus stables. Le même phénomène est présent pour les mesures de validité dans les deux milieux.ConclusionsEn conclusion, les résultats montrent que les ASC peuvent recueillir certains types de données communautaires de façon exacte et fiable, ce qui permet de réduire les coûts, particulièrement dans les milieux où les ressources se font rares.

Volunteers Motives in Relation to their Task Preference in Health Service Delivery: A Case of West Kenya

Background: According to the World Health Organization (WHO), human resources is the key ingredient to the effective functioning of health systems. The growing human resource crisis in low-income countries has re-energized the debate concerning the role of community health volunteers in health service delivery. Researchers have studied task-shifting among community volunteers focusing on its impact on health outcomes. This study focused on how task preference could be related to volunteer motives in an African setting. Methods: We carried out a cross-sectional survey with the aim to investigate the relationship between motives and task preference among health volunteers compared with non-volunteers matched by gender, residence, and education in Western Kenya. The eight motives that were taken into account in the present study were obtained from existing literature, and tasks were derived from the common health activities undertaken by volunteers in Kenya. We recorded the preference of 1062 respondents for each of the tasks on a 1-5 Likert scale. The task preference among volunteers on the basis of motives and the status of the volunteers were compared. Results: Long-term health tasks such as mother and child healthcare, home visiting and curative care were significantly more associated with altruistic than with material gain motives (p=0.00). Short-term tasks such as helping in disease outbreaks, and participation in immunization campaigns were associated with both altruistic and material gain motives. The self-seeking motives tend to be associated only with short-term tasks. Conclusion: The preference for long-term health tasks was associated with non self-seeking motives; while short-term tasks were associated with both non self-seeking and self-seeking motives. It was concluded that the assessment of the motives of the volunteers was critical in assigning tasks to volunteers.

Contextual variations in costs for a community health strategy implemented in rural, peri-urban and nomadic sites in Kenya

BackgroundMany low and middle income countries have developed community health strategies involving lay health workers, to complement and strengthen public health services. This study explores variations in costing parameters pertinent to deployment of community health volunteers across different contexts outlining considerations for costing program scale-up.MethodsThe study used quasi experimental study design and employed both quantitative and qualitative methods to explore community health unit implementation activities and costs and compare costs across purposively selected sites that differed socially, economically and ecologically. Data were collected from November 2010 to December 2013 through key informant interviews and focus group discussions. We interviewed 16 key informants (eight District community health strategy focal persons, eight frontline field officers), and eight focus group discussions (four with community health volunteers and four with community health committee) and 560 sets of monthly cost data. Cost data were tabulated using Microsoft Excel. Qualitative data were transcribed and coded using a content analysis framework.ResultsFour critical elements: attrition rates for community health volunteers, geography and population density, livelihood opportunity costs and benefits, and social opportunity benefits, drove cost variations across the three sites. Attrition rate was highest in peri-urban site where population is highly mobile and lowest in nomadic site. More households were covered by community health workers in the peri-urban area making per capita costs considerably less than in the nomadic settings where long distances had to be covered to reach sparsely distributed households. Livelihood opportunity costs for Community Health Volunteers were highest in nomadic setting, while peri-urban ones reported substantial employability benefits resulting from training. Social opportunity benefits were highest in rural site.ConclusionsResults show that costs of implementing community health strategy varied due to different area contextual factors in Kenya. This study identified four critical elements that drive cost variations: attrition rates for community health volunteers, geography and population density, livelihood opportunity costs and benefits, and social opportunity benefits. Health programme managers and policy-makers need to pay attention to details of contextual factors in costing for effective implementation of community health strategies.

Demographic entrapment is preventing Africa from reaching MDG 1

www.thelancet.com Vol 380 November 3, 2012 1557 anomalies in children younger than 5 years was 0·511 million or 3·8 deaths per 1000 livebirths. This is 52% higher than the mortality risk due to congenital disorders in the UK. As we highlighted, verbal autopsy studies, on which we rely for causes of most under-5 deaths, are subject to misclassifi cation. Deaths due to congenital heart disease as the most common fatal congenital anomaly are especially prone to misclassifi cation with respiratory conditions. Furthermore, even in high-income countries with access to advanced technology, vital registration certifi cation probably also under diagnoses congenital disorders. Although these data limitations make underestimation likely, the compartmental model applied by Modell and colleagues, with birth prevalence and case fatality rates, could result in overestimation for several reasons. First, populationbased prevalence data are rare outside high-income settings and often for single disorders—eg, neural tube defects. Single-disorder studies might deliberately select high-prevalence populations. Although some anomalies vary predictably with maternal age, or are believed to be constant, there is considerable uncertainty in applying prevalence estimates derived from largely European populations to populations with diff erent fertility patterns, or genetic and environmental contexts. Second, some estimates include stillbirths and terminations as well as livebirths. The cited birth prevalence of 22·5 per 1000 total births could be further aff ected by double-counting since “a baby/fetus with several anomalies is counted once within each class of anomaly... the number in diff erent classes cannot be added to reach a total number of babies/fetuses”, despite eff orts to minimise double counting. Third, not all congenital anomalies are fatal, yet population-based, cause-specifi c fatality rate data are lacking for varying care settings, forcing reliance on historical data or expert opinion. Lastly, in low-income countries, children with congenital anomalies have an independently higher risk of dying fi rst from other causes. In conclusion, although mortality from congenital anomalies is probably under estimated, it is probably not to the extent suggested. Much of the heavy burden of congenital disorders is through long-term impairment, especially in the absence of eff ective care. We endorse our colleagues’ point that better data on the true disease burden of congenital anomalies, mortality, and morbidity, are important.

The Contribution of Community Based Volunteer Workforce Towards the Millenium Development Goals in Nyando District, Kenya

Africa is behind in all Millennium Development Goals (MDGs) indicators and are unlikely to achieve them by 2015. This calls for innovations to accelerate progress. Community Based Volunteerism (CBV) is one such innovation. Volunteers are people who work on behalf of others without pay or tangible gain, (Decker 2003). Volunteerism exists in all cultures and religions. It enhances solidarity and reciprocity among people. It is valued as a means of responding to human resource needs, most urgent in Africa because of limited resources (Smith, 1998b). This paper presents results of a study on the contribution of CBVs to efforts towards the MDGs in Nyakach District, Western Kenya. The study was cross sectional, descriptive and exploratory in design. The objective was to describe the contribution of volunteers in services relevant to the achievement of the MDGs in the study area, using quantitative and qualitative data collection methods. Results: Services rendered by volunteers were relevant to MDGs 1, 2, 4, 5, 6, and 7. Majority of volunteers spent 6-10 hours in a week offering voluntary services. This is equivalent to

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20 per person per month, for 40 volunteers serving 5,000 people. Thus they contribute USD 9,600 per year, which is 4% budget of

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170,000 the population at recommended

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34 per capita per year. Majority of volunteers (70%) in study area had served for more than five years, indicating a reasonable retention rate. Conclusion: The study concluded that volunteers make substantial contribution to efforts, and budget towards the MDG relevant services, and are vital if MDGs are to be achieved. Due to the budgetary strains and human resource crisis, volunteerism presents an alternative of providing services. It should become a way of life for every citizen, as it is the only way most governments could progress towards the MDGs.