Kenya is characterized by high unmet need for family planning (FP) and high unplanned pregnancy, in a context of urban population explosion and increased urban poverty. It witnessed an improvement of its FP and reproductive health (RH) indicators in the recent past, after a period of stalled progress. The paper describes inequities in modern contraceptive use, types of methods used, and the main sources of contraceptives in urban Kenya; examines the extent to which differences in contraceptive use between the poor and the rich widened or shrank over time; and attempts to relate these findings to the FP programming context, with a focus on whether the services are increasingly reaching the urban poor. It uses data from the 1993, 1998, 2003 and 2008/09 Kenya demographic and health survey. The authors found a dramatic change in contraceptive use between 2003 and 2008/09 that resulted in virtually no gap between the poor and the rich in 2008/09, by contrast to the period 1993–1998 during which the improvement in contraceptive use did not significantly benefit the urban poor.
Equitable health services
With much of the world’s population still lacking access to basic health services, evidence shows that community-based interventions are effective for improving health-care utilization and outcomes when integrated with facility-based services. Community involvement is the cornerstone of local, equitable and integrated primary health care (PHC). Policies and actions to improve PHC must regard community members as more than passive recipients of health care. Instead, they should be leaders with a substantive role in planning, decision-making, implementation and evaluation. Metrics used for evaluating PHC and Universal health coverage largely focus on clinical health outcomes and the inputs and activities for achieving them. Little attention is paid to indicators of equitable coverage or measures of overall well-being, ownership, control or priority-setting, or to the extent to which communities have agency. In the future, communities must become more involved in evaluating the success of efforts to expand PHC.
This qualitative study was conducted in two malaria-endemic regions of Kenya - South Coast and Busia. Participant selection was purposive and criterion based. A total of 20 focus group discussions, 22 in-depth interviews, and 18 exit interviews were conducted. While support for local child immunisation programmes exists, limited understanding about vaccines and what they do was evident among younger and older people, particularly men. In general, parents and caregivers weigh several factors - such as personal opportunity costs, resource constraints, and perceived benefits - when deciding whether or not to have their children vaccinated, and the decision often is influenced by a network of people, including community leaders and health workers. The study raises issues that should inform a communications strategy and guide policy decisions within Kenya on eventual malaria vaccine introduction. Unlike the current practice, where health education on child welfare and immunisation focuses on women, the communications strategy should equally target men and women in ways that are appropriate for each gender, the authors argue. It should involve influential community members and provide needed information and reassurances about immunisation. Efforts also should be made to address concerns about the quality of immunisation services, including health workers' interpersonal communication skills.
Home Based Management of fever (HBM) was introduced as a national policy in Uganda to increase access to prompt presumptive treatment of malaria. Pre-packed Chloroquine/Fansidar combination is distributed to febrile children under-five years in the community. Persisting fever or 'danger signs' are referred to the health centre. Functioning referral to health centres is a critical assumption in HBM. We assessed overall referral rate, causes of referral, referral completion and reasons for non-completion under the HBM strategy.
Effective and simple interventions and tools exist that can be used to either prevent, treat or rehabilitate patients suffering from infectious diseases of poverty (IDoP). The delivery of these interventions and tools to the affected populations, however, has proven difficult due to weak public health systems in many disease-endemic countries. Disease control and public health programmes are increasingly advocating community-based delivery strategies and interventions. These depend, to a large degree, on trained community health workers whose performance in various areas of health care such as maternal and child health has been the subject of rigorous recent systematic reviews. Community-based delivery platforms are increasingly being proposed not only to ensure sustainability and combat co-infections, but also to build capacity for integration of NTDs with existing malaria, tuberculosis, and HIV/AIDS programs for which more sophisticated healthcare delivery systems already exist. This thematic series of eight papers provides an overview on infectious diseases of poverty and integrated community-based interventions, describes the analytical framework and the methodology used to guide the systematic reviews, reports findings for the effectiveness of community-based interventions for the prevention and control of helminthic NTDs, non-helminthic NTDs, malaria, HIV/AIDS and tuberculosis and proposes a way forward. While previous reviews focus on process and effectiveness of integrated community-based interventions under real life field conditions, this series of papers evaluates the efficacy of such interventions with respect to disease or prevention outcomes.
The authors of this study compared medical abortion practised at home and in clinics in terms of effectiveness, safety and acceptability. A systematic search for randomized controlled trials and prospective cohort studies comparing home-based and clinic-based medical abortion was conducted. Nine studies met the inclusion criteria. Complete abortion was achieved by 86–97% of the women who underwent home-based abortion and by 80–99% of those who underwent clinic-based abortion. Pooled analyses from all studies revealed no difference in complete abortion rates between groups. Serious complications from abortion were rare. Women who chose home-based medical abortion were more likely to be satisfied, to choose the method again and to recommend it to a friend than women who opted for medical abortion in a clinic.
The PHIT Partnership’s health systems support aligns with the World Health Organisation’s six health systems building blocks. Health system strengthening (HSS) activities focus across all levels of the health system to improve health care access, quality, delivery, and health outcomes. Interventions are concentrated on three main areas: targeted support for health facilities, quality improvement initiatives, and a strengthened network of community health workers. The impact of health system strengthening activities will be assessed using population-level outcomes data collected through oversampling of the demographic and health survey (DHS) in the intervention districts. The overall impact evaluation is complemented by an analysis of trends in facility health care utilisation. A comprehensive costing project captures the total expenditures and financial inputs of the health care system to determine the cost of systems improvement. Building on early successes, the work of the Rwanda PHIT Partnership approach to HSS has already seen noticeable increases in facility capacity and quality of care. The rigorous planned evaluation of the Partnership’s HSS activities will contribute to global knowledge about intervention methodology, cost, and population health impact.
Malnutrition in Congo-Brazzaville causes more than a quarter of deaths among children under five, according to United Nations Children's Fund (UNICEF). In response, on 20 October 2010, the Act Now, No Woman Should Die Giving Life campaign was launched across the country. It aims to reduce maternal and child mortality, and involves the government, three United Nations (UN) agencies, civil society and private partners. It aims to reduce the maternal mortality rate of 781 per 100,000 live births, as well as child mortality. UNICEF also pointed out health inequities, as the rich have access to faster essential interventions than the poor and stressed that reducing this inequality is essential to achieve the Millennium Development Goals related to health. The Congolese Minister for Health and Population assured that adoption of the new national roadmap will accelerate reduction in mortality rates. He said that since 2008 pregnant women and children aged 5-15 have been able to access free malaria treatment, and from January 2011 pregnant women will be able to get free Caesarean sections.
During the Ebola virus disease (EVD) epidemic in Liberia, contact tracing was implemented to rapidly detect new cases and prevent further transmission. The authors describe the scope and characteristics of this contact tracing and assess its performance during the 2014–2015 epidemic in six counties. Positive predictive value (PPV) was defined as the proportion of traced contacts who were identified as potential cases. Contact tracing was initiated for 26.7% of total EVD cases and detected 3.6% of all new cases during the period covered, with a PPV of 1.4%. Potential cases were more likely to be detected early in the outbreak; to hail from rural areas; report multiple exposures and symptoms; have household contact or direct bodily or fluid contact; and report nausea, fever, or weakness, as compared to contacts who completed monitoring. Contact tracing was identified to be a critical intervention in Liberia and represented one of the largest contact tracing efforts during an epidemic in history. While there were notable improvements in implementation over time, the study data suggest there were limitations to its performance—particularly in urban districts and during peak transmission. Recommendations for improving performance include integrated surveillance, decentralized management of multidisciplinary teams, comprehensive protocols, and community-led strategies.
This study investigates contextual factors associated with treatment-seeking behaviour and higher-risk sexual conduct of men symptomatic of sexually transmitted infections (STIs) in Botswana. At the heart of Botswana's epidemic lies men's reluctance to seek medical treatment, engaging in unprotected sex, and having sex with multiple partners while symptomatic of an STI. The odds of engaging in unprotected sex while symptomatic of an STI were significantly higher among teenage males, males in urban households, where age differences between partners was higher, in married men and men with more than one sexual partner. Having sought medical treatment from hospitals, clinics and health workers, as opposed to consulting traditional healers, significantly reduced the odds of having had unprotected sex while infected with an STI. The results indicate the need to encourage men to utilise public healthcare services. The public health sector in Botswana needs to provide healthcare services that are user-friendly for men. Special attention needs to be paid to boys' socialisation towards gender norms, and men are to be encouraged to play a responsible role in HIV prevention.