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Routine vaccination annually prevents millions of deaths worldwide but is underutilized in sub-Saharan Africa (SSA). The complexity of socio-cultural factors impacting vaccine uptake is not well understood. Hence, this paper aims to review the socio-cultural determinants of vaccine uptake and visualize their interrelationships. We conducted a literature search using Pubmed and Embase databases, including articles published from 2000 to 2019 describing socio-cultural demand-side determinants for vaccine uptake. Using the Andersen and Newman Framework of Health Services Utilization, demand-side determinants were categorized as predisposing, enabling or need factors. A qualitative system dynamics approach was employed to visualize how these factors and their dynamic interrelationships influence vaccine uptake. This visualization, by means of a causal-loop diagram (CLD), was mostly based on a qualitative input, with the majority being statements of the authors. These statements were abstracted from the papers found in the review. Quantification was done by counting direct (statistical) associations between each determinant and 'timely and full routine immunization coverage'. A total of 90 articles, primarily from Nigeria (n = 23), Ethiopia (n = 17) and Kenya (n = 11), met the inclusion criteria. We find that maternal autonomy and the perceived benefits caregivers attach to vaccination and exert their influences on many other factors through several feedback loops, thereby influencing timely and full routine immunization coverage. Utilization of health services (supply-related) and access to information (demand-related) were considered as high-potential leverage points. Quantification has shown that maternal autonomy and perceived benefit have an unclear evidence base. Future research should focus on these key players as they play a central role in multiple complex pathways, through which they could influence the uptake of vaccines in SSA. [ABSTRACT FROM AUTHOR]

Effective citizen engagement is crucial for the success of social health insurance, yet little is known about the mechanisms used to involve citizens in low- and middle-income countries. This paper explores citizen engagement efforts by the National Health Insurance Fund (NHIF) and their impact on health insurance coverage within rural informal worker households in western Kenya. Our study employed a mixed methods design, including a cross-sectional household survey (n  = 1773), in-depth household interviews (n  = 36), six focus group discussions with community stakeholders and key informant interviews (n  = 11) with policymakers. The findings reveal that NHIF is widely recognized, but knowledge of its services, feedback mechanisms and accountability systems is limited. NHIF enrolment among respondents is low (11%). The majority (63%) are aware of NHIF, but only 32% know about the benefit package. There was higher awareness of the benefit package (60%) among those with NHIF compared to those without (28%). Satisfaction with the NHIF benefit package was expressed by only 48% of the insured. Nearly all respondents (93%) are unaware of mechanisms to provide feedback or raise complaints with NHIF. Of those who are aware, the majority (57%) mention visiting NHIF offices for assistance. Most respondents (97%) lack awareness of NHIF's performance reporting mechanisms and express a desire to learn. Negative media reports about NHIF's performance erode trust, contributing to low enrolment and member attrition. Our study underscores the urgency of prioritizing citizen engagement to address low enrolment and attrition rates. We recommend evaluating current citizen engagement procedures to enhance citizen accountability and incorporate their voices. Equally important is the need to build the capacity of health facility staff handling NHIF clients in providing information and addressing complaints. Transparency and information accessibility, including the sharing of performance reports, will foster trust in the insurer. Lastly, standardizing messaging and translations for diverse audiences, particularly rural informal workers, is crucial. [ABSTRACT FROM AUTHOR]

The proliferation of mobile enabled instant credit products (digital credit) across emerging markets and developing economies poses challenges for policy-makers and practitioners that seek to expand access to credit while protecting consumers. The Kenya market, which experienced tremendous commercial innovation and growth from 2012 to 2022, but also significant consumer harms and unequal competition, offers a valuable reference case for actors in other markets facing rapid expansion of new fintech products and firms. Despite the substantial and often polarized debate around the country's experience, there has been little systematic effort to capture and interpret key facts from the development of the digital credit market in Kenya during its first decade. This paper aims to fill that gap by providing a policy case study informed by original interviews of key stakeholders and extensive review of related academic and grey literature. The analysis suggests that policy responses were often inadequate to address the growing risks in Kenya's digital credit market and presents five policy reflections from Kenya's experience to support consumer protection and competition in emerging digital credit markets. [ABSTRACT FROM AUTHOR]

Private sector engagement in health reform has been suggested to help reduce healthcare inequities in sub-Saharan Africa, where populations with the most need seek the least care. We study the effects of African Health Markets for Equity (AHME), a cluster randomized controlled trial carried out in Kenya from 2012 to 2020 at 199 private health clinics. AHME included four clinic-level interventions: social health insurance, social franchising, SafeCare quality-of-care certification programme and business support. This paper evaluates whether AHME increased the capacity of private health clinics to serve poor clients while maintaining or enhancing the quality of care provided. At endline, clinics that received AHME were 14.5 percentage points (pp) more likely to be empanelled with the National Health Insurance Fund (NHIF), served 51% more NHIF clients and served more clients from the middle three quintiles of the wealth distribution compared to control clinics. Comparing individuals living in households near AHME treatment and control clinics (N  = 8241), AHME led to a 6.7-pp increase in the probability of holding any health insurance on average. We did not find any additional effect of AHME on insurance holding among poor households. We measured quality of care using a standardized patient (SP) experiment (N  = 596 SP–provider interactions) where recruited and trained SPs were randomized to present as either 'not poor', and able to afford all services provided, or 'poor' by telling the provider they could only afford ∼300 Kenyan Shillings (US$3) in fees. We found that poor SPs received lower levels of both correct and unnecessary services, and AHME did not affect this. More work must be done to ensure that clients of all wealth levels receive high-quality care. [ABSTRACT FROM AUTHOR]

Public-sector healthcare providers are on the frontline of family planning service delivery in low- and middle-income countries like Kenya, yet research suggests public-sector providers are frequently absent. The current prevalence of absenteeism in Western Kenya, as well as the impact on family planning clients, is unknown. The objective of this paper is to quantify the prevalence of public-sector healthcare provider absenteeism in this region of Kenya, to describe the potential impact on family planning uptake and to source locally grounded solutions to provider absenteeism. We used multiple data collection methods including unannounced visits to a random sample of 60 public-sector healthcare facilities in Western Kenya, focus group discussions with current and former family planning users, key informant interviews (KIIs) with senior staff from healthcare facilities and both governmental and non-governmental organizations and journey mapping activities with current family planning providers and clients. We found healthcare providers were absent in nearly 60% of unannounced visits and, among those present, 19% were not working at the time of the visit. In 20% of unannounced visits, the facility had no providers present. Provider absenteeism took many forms including providers arriving late to work, taking an extended lunch break, not returning from lunch or being absent for the entire day. While 56% of provider absences resulted from sanctioned activities such as planned vacation, sick leave or off-site work responsibilities, nearly half of the absences were unsanctioned, meaning providers were reportedly running personal errands, intending to arrive later or no one at the facility could explain the absence. Key informants and focus group participants reported high provider absence is a substantial barrier to contraceptive use, but solutions for resolving this problem remain elusive. Identification and rigorous evaluation of interventions designed to redress provider absenteeism are needed. [ABSTRACT FROM AUTHOR]

Background: Helminth (worm) infections cause morbidity among poor communities worldwide. An influential study conducted in Kenya in 1998-99 reported that a school-based drug-and-educational intervention had benefits regarding worm infections and school attendance. Effects were seen among children treated with deworming drugs, untreated children in intervention schools and children in nearby non-intervention schools. Combining these effects, the intervention was reported to increase school attendance by 7.5% in treated children. Effects on other outcomes (worm infections, anaemia, nutritional status and examination performance) were also investigated.Methods: In this pure replication, we used data provided by the original authors to re-analyse the study according to their methods. We compared these results against those presented in the original paper.Results: Although most results were reproduced as originally reported, we identified discrepancies of several types between the original findings and re-analysis. For worm infections, re-analysis showed reductions similar to those originally reported. For anaemia prevalence, in contrast to the original findings, re-analysis found no evidence of benefit. For nutritional status, both original findings and re-analysis described modest evidence for a small improvement. For school attendance, re-analysis showed benefits similar to those originally found in intervention schools for both children who did and those who did not receive deworming drugs. However, after correction of coding errors, there was little evidence of an indirect effect on school attendance among children in schools close to intervention schools. Combining these effects gave a total increase in attendance of 3.9% among treated children, which was no longer statistically significant. As in the original results, re-analysis found no effect of the intervention on examination performance.Conclusions: Re-applying analytical approaches originally used, but correcting various errors, we found little evidence for some previously-reported indirect effects of a deworming intervention. Effects on worm infections, nutritional status, examination performance and school attendance on children in intervention schools were largely unchanged. [ABSTRACT FROM AUTHOR]

Background This paper presents a descriptive analysis of the perceptions of Kenyan midwifery educators regarding the early impact of coronavirus disease 2019 (COVID-19) on the continuity of midwifery education. Methods A cross-sectional online survey was conducted among 51 midwifery/clinical medicine educators from 35 diploma training colleges from all eight regions of Kenya. Educators' concerns and satisfaction regarding the delivery of training during the early phases of the pandemic were expressed as proportions on a three-point Likert scale. Results Of the educators, 76% were extremely concerned about face-to-face teaching during the pandemic; 96% of educators had started delivering virtual teaching (VT), with only 41% being extremely confident in facilitating VT; and 97% were unsatisfied with the measures in place in their institutions to continue face-to-face teaching. Conclusion To minimise the impact of COVID-19 on midwifery education in Kenya, capacity building for VT and mitigation measures for safe in-person training are urgently needed. [ABSTRACT FROM AUTHOR]

Study Question: Is bacterial vaginosis (BV) associated with fecundability?Summary Answer: Women with BV may be at increased risk for sub-fecundity.What Is Known Already: While BV has been associated with poor IVF outcomes, the association between vaginal microbiota disruption and non-medically assisted conception has not been thoroughly explored.Study Design, Size, Duration: Kenyan women with fertility intent were enrolled in prospective cohort that included monthly preconception visits with vaginal fluid specimen collection and pregnancy testing. Four hundred fifty-eight women attempting pregnancy for ≤3 menstrual cycles at enrollment were eligible for this fecundability analysis.Participants/materials, Setting, Methods: At monthly preconception visits, participants reported the first day of last menstrual period and sexual behavior, underwent pregnancy testing and provided vaginal specimens. Discrete time proportional probabilities models were used to estimate fecundability ratios (FRs) and 95% CI in menstrual cycles with and without BV (Nugent score ≥ 7) at the visit prior to each pregnancy test. We also assessed the association between persistent BV (BV at two consecutive visits) and fecundability.Main Results and the Role Of Chance: Participants contributed 1376 menstrual cycles; 18.5% (n = 255) resulted in pregnancy. After adjusting for age, frequency of condomless sex and study site, BV at the visit prior to pregnancy testing was associated with a 17% lower fecundability (adjusted FR (aFR) 0.83, 95% CI 0.6-1.1). Persistent BV was associated with a 43% reduction in fecundability compared to cycles characterized by optimal vaginal health (aFR 0.57, 95% CI 0.4-0.8).Limitations, Reasons For Caution: Detection of vaginal microbiota disruption using Gram stain and a point-of-care test for elevated sialidase identified a non-optimal vaginal environment, but these non-specific methods may miss important relationships that could be identified by characterizing individual vaginal bacteria and bacterial communities using molecular methods. In addition, results may be subject to residual confounding by condomless sex as this was reported for the prior month rather than for the fertile window during each cycle.Wider Implications Of the Findings: Given the high global prevalence of BV and infertility, an association between BV and reduced fecundability could have important implications for a large number of women who wish to conceive. Multi-omics approaches to studying the vaginal microbiota may provide key insights into this association and identify potential targets for intervention.Study Funding/competing Interest(s): This work was supported by a National Institutes of Health grant (NICHD R01 HD087346-R.S.M.). R.S.M. received additional support for mentoring (NICHD K24 HD88229). E.M.L. was supported by pre- and post-doctoral fellowships (NIAID T32 AI07140, NICHD F32 HD100202). Data collection and management were made possible using REDCap electronic data capture tools hosted at the University of Washington's Institute of Translational Health Science supported by grants from NCATS/NIH (UL1 TR002319). The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. R.S.M. receives research funding, paid to the University of Washington, from Hologic Corporation, and has received honoraria for consulting from Lupin Pharmaceuticals. L.E.M. receives research funding, paid to the University of Washington, from Hologic Corporation, and has received honoraria for service on scientific advisory boards from Hologic and Nabriva Therapeutics.Trial Registration Number: N/A. [ABSTRACT FROM AUTHOR]

Background The relationship between HIV and poverty is complex and recent studies reveal an urban--rural divide that is not well understood. This paper examines the urban--rural disparity in the relationship between poverty and HIV infection in Kenya, with particular reference to possible explanations relating to social cohesion/capital and other moderating factors. Methods Multilevel logistic regression models are applied to nationally-representative samples of 13 094 men and women of reproductive age from recent Kenya Demographic and Health Surveys. Results The results confirm a disproportionate higher risk of HIV infection among the urban poor, despite a general negative association between poverty and HIV infection among rural residents. Estimates of intra-community correlations suggest lower social cohesion in urban than rural communities. This, combined with marked socio-economic inequalities in urban areas is likely to result in the urban poor being particularly vulnerable. The results further reveal interesting cultural variations and trends. In particular, recent declines in HIV prevalence among urban residents in Kenya have been predominantly confined to those of higher socio-economic status. Conclusion With current rapid urbanization patterns and increasing urban poverty, these trends have important implications for the future of the HIV epidemic in Kenya and similar settings across the sub-Saharan Africa region. [ABSTRACT FROM AUTHOR]

Policies as they are written often mask the power relations behind their creation (Hull, 2008). As a result, not only are policies that appear neat on the page frequently messy in their implementation on the ground, but the messiness of implementation, and implementation science, often brings these hidden power relations to light. In this paper, we examine the process by which different data sources were generated within a programme meant to increase access to quality private healthcare for the poorest populations in Kenya, how these sources were brought and analyzed together to examine gender bias in the large-scale rollout of Kenya's National Hospital Insurance Fund (NHIF) beyond public hospitals and civil service employees, and how these findings ultimately were developed in real time to feed into the NHIF reform process. We point to the ways in which data generated for implementation science purposes and without a specific focus on gender were analyzed with a policy implementation analysis lens to look at gender issues at the policy level, and pay particular attention to the role that the ongoing close partnership between the evaluators and implementers played in allowing the teams to develop and turn findings around on short timelines. In conclusion, we discuss possibilities for programme evaluators and implementers to generate new data and feed routine monitoring data into policy reform processes to create a health policy environment that serves patients more effectively and equitably. Implementation science is generally focused on programmatic improvement; the experiences in Kenya make clear that it can, and should, also be considered for policy improvement. [ABSTRACT FROM AUTHOR]

Over the past 30 years, scholars have criticized the propensity of the international media to reproduce damaging and racist stereotypes about Africa. How do foreign correspondents, who are key actors in the production of Africa's media image, position themselves in relation to this criticism? Based on 35 interviews conducted with correspondents in Kenya and South Africa between 2013 and 2017, I find that many correspondents recognize the negative contributions of the news industry to representational Othering, thereby agreeing with the general tenets of the criticism. This paper is an in-depth exploration of this phenomenon, which I call postcolonial reflexivity. I outline the features of this postcolonial reflexivity, discuss its impact on journalistic practices, and explore the reasons for its prevalence among correspondents. Overall, the research contributes to bridging the gap between the textual orientation of postcolonial studies and the inclination for analyzing production practices in journalism studies. [ABSTRACT FROM AUTHOR]

Integration of parallel health commodities supply chains into one national supply chain is becoming more common globally as national health systems are strengthened and organizations realize the potential for increased effectiveness and cost reduction from integration. UNICEF conducted a 10-week pilot to integrate its supply chain for nutrition commodities into the national Ministry of Health supply chain for medical commodities. This paper is a cost analysis of the integration process in two counties, comparing four scenarios of cost structures before, during and after integration. It found as a result of integration, within the two counties involved in the 10-week pilot period, 14% cost savings were obtained on transport, warehousing and staff costs, when compared with the pre-integration total cost structure, and 37% when extrapolated out to a year as initial capacity development (training) costs were spread over a longer period. When looking only at recurrent costs and not one-time investments in capacity development, cost savings increased to 42%. More of the costs post-integration were invested in capacity building activities to strengthen the Kenyan health system, as opposed to pre-integration when more costs went towards higher transportation costs. Besides the positive impact on costs and savings generation, integration increased the reliability of forecasting and reporting, improved communication and coordination across stakeholders, decreased stock-outs and strengthened the capacity of the health system. This article also includes lessons learned and challenges of the integration process, useful to other country programmes considering similar integration. Because of the potential for a positive impact on health systems strengthening, combined with decreased costs and enhanced accountability, this is an exciting change not only for scale-up domestically, but for donors and implementing organizations to consider more broadly in other countries. [ABSTRACT FROM AUTHOR]

List experiments (LEs) are an increasingly popular survey research tool for measuring sensitive attitudes and behaviors. However, there is evidence that list experiments sometimes produce unreasonable estimates. Why do list experiments "fail," and how can the performance of the list experiment be improved? Using evidence from Kenya, we hypothesize that the length and complexity of the LE format make them costlier for respondents to complete and thus prone to comprehension and reporting errors. First, we show that list experiments encounter difficulties with simple, nonsensitive lists about food consumption and daily activities: over 40 percent of respondents provide inconsistent responses between list experiment and direct question formats. These errors are concentrated among less numerate and less educated respondents, offering evidence that the errors are driven by the complexity and difficulty of list experiments. Second, we examine list experiments measuring attitudes about political violence. The standard list experiment reveals lower rates of support for political violence compared to simply asking directly about this sensitive attitude, which we interpret as list experiment breakdown. We evaluate two modifications to the list experiment designed to reduce its complexity: private tabulation and cartoon visual aids. Both modifications greatly enhance list experiment performance, especially among respondent subgroups where the standard procedure is most problematic. The paper makes two key contributions: (1) showing that techniques such as the list experiment, which have promise for reducing response bias, can introduce different forms of error associated with question complexity and difficulty; and (2) demonstrating the effectiveness of easy-to-implement solutions to the problem. [ABSTRACT FROM AUTHOR]

Background Although Shigella is an important cause of diarrhea in Kenyan children, robust research platforms capable of conducting incidence-based Shigella estimates and eventual Shigella- targeted clinical trials are needed to improve Shigella -related outcomes in children. Here, we describe characteristics of a disease surveillance platform whose goal is to support incidence and consequences of Shigella diarrhea as part of multicounty surveillance aimed at preparing sites and assembling expertise for future Shigella vaccine trials. Methods We mobilized our preexisting expertise in shigellosis, vaccinology, and diarrheal disease epidemiology, which we combined with our experience conducting population-based sampling, clinical trials with high (97%–98%) retention rates, and healthcare utilization surveys. We leveraged our established demographic surveillance system (DSS), our network of healthcare centers serving the DSS, and our laboratory facilities with staff experienced in performing microbiologic and molecular diagnostics to identify enteric infections. We joined these resources with an international network of sites with similar capabilities and infrastructure to form a cohesive scientific network, designated Enterics for Global Health (EFGH), with the aim of expanding and updating our knowledge of the epidemiology and adverse consequences of shigellosis and enriching local research and career development priorities. Conclusions Shigella surveillance data from this platform could help inform Shigella vaccine trials. [ABSTRACT FROM AUTHOR]

. We have previously described the content of a text by Woods and Russell, An Introduction to Medical Statistics, compared it with Principles of Medical Statistics by Hill and set both volumes against the background of vital statistics up until 1937. The two books mark a watershed in the history of medical statistics. Very little has been recorded about the life and career of the first author of the earlier textbook, who was a Fellow of the Royal Statistical Society for at least 25 years, an omission which we can now rectify with this paper. We describe her education, entry into medical statistics, relationship with Major Greenwood and her subsequent career and life in Ceylon, Kenya, Australia, England and South Africa. [ABSTRACT FROM AUTHOR]

As a result of the increasing number of orphans in sub-Saharan Africa, numerous programmes have been initiated to facilitate the care and support of orphaned and vulnerable children. This paper reports on a community-based capital cash transfer initiative in Kenya and explores its role in building orphan competent and supportive communities through its participatory project cycle. Using a mixture of individual and group interviews, 300 orphaned children and 110 adults involved in this initiative were interviewed using open-ended questions. A thematic analysis of the data revealed that many of the communities participating in this programme had become more united and active in the support of orphaned children following the mobilization of much needed economic, political and social support resources. Despite many difficulties, largely due to the complexity of communities, we conclude that community-based capital cash transfer initiatives can facilitate the building of orphan competent communities. [ABSTRACT FROM AUTHOR]

Background: Kenya recently transitioned from a paper to an electronic system for recording and reporting of tuberculosis (TB) data. Methods: During September-October 2013, the data quality of the new system was evaluated through an audit of data in pa per source documents and in the national electronicsystem, and an analysis of all 99 281 cases reported in 2012. Results: While the new electronic system overall is robust, this assessment demonstrated limitations in the concordance and completeness of data reaching the national level. Conclusions: Additional oversight and training in data entry are needed to strengthen TB surveillance data quality in Kenya. [ABSTRACT FROM AUTHOR]

There is growing concern that health policies and programmes may be contributing to disparities in health and wealth between and within households in low-income settings. However, there is disagreement concerning which combination of health and non-health sector interventions might best protect the poor. Potentially promising interventions include those that build on the social resources that have been found to be particularly critical for the poor in preventing and coping with illness costs. In this paper we present data on the role of one form of social resource—community-based organizations (CBOs)—in household ability to pay for health care on the Kenyan coast. Data were gathered from a rural and an urban setting using individual interviews (n = 24), focus group discussions (n = 18 in each setting) and cross-sectional surveys (n = 294 rural and n = 576 urban households). We describe the complex hierarchy of CBOs operating at the strategic, intermediate and local level in both settings, and comment on the potential of working through these organizations to reach and protect the poor. We highlight the challenges around several interventions that are of particular international interest at present: community-based health insurance schemes; micro-finance initiatives; and the removal of primary care user fees. We argue the importance of identifying and building upon organizations with a strong trust base in efforts to assist households to meet treatment costs, and emphasize the necessity of reducing the costs of services themselves for the poorest households. [ABSTRACT FROM PUBLISHER]

This paper describes and evaluates the budgeting and planning processes in public hospitals in Kenya. We used a qualitative case study approach to examine these processes in two hospitals in Kenya. We collected data by in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals (n = 72), a review of documents, and non-participant observations within the hospitals over a 7 month period. We applied an evaluative framework that considers both consequentialist and proceduralist conditions as important to the quality of priority-setting processes. The budgeting and planning process in the case study hospitals was characterized by lack of alignment, inadequate role clarity and the use of informal priority-setting criteria. With regard to consequentialist conditions, the hospitals incorporated economic criteria by considering the affordability of alternatives, but rarely considered the equity of allocative decisions. In the first hospital, stakeholders were aware of - and somewhat satisfied with - the budgeting and planning process, while in the second hospital they were not. Decision making in both hospitals did not result in reallocation of resources. With regard to proceduralist conditions, the budgeting and planning process in the first hospital was more inclusive and transparent, with the stakeholders more empowered compared to the second hospital. In both hospitals, decisions were not based on evidence, implementation of decisions was poor and the community was not included. There were no mechanisms for appeals or to ensure that the proceduralist conditions were met in both hospitals. Public hospitals in Kenya could improve their budgeting and planning processes by harmonizing these processes, improving role clarity, using explicit priority-setting criteria, and by incorporating both consequentialist (efficiency, equity, stakeholder satisfaction and understanding, shifted priorities, implementation of decisions), and proceduralist (stakeholder engagement and empowerment, transparency, use of evidence, revisions, enforcement, and incorporating community values) conditions. [ABSTRACT FROM AUTHOR]

Background Kawasaki disease (kDa) is a childhood vasculitides that affects small and medium-sized arteries. It is self-limiting but when left untreated can cause coronary artery aneurysms in about 25% of children1. The diagnosis is clinical and is made with the criteria of fever for at least five days, and at least four out of five other clinical signs: bilateral non-exudative conjunctivitis, oral mucous membrane changes, peripheral extremity changes, polymorphous rash, and cervical lymphadenopathy. Incomplete kDa is diagnosed with fever for at least five days and at least 2–3 of the principal signs, with suggestive lab investigations and lack of an alternative diagnosis1. kDa is named after Dr Tomisaku Kawasaki who first described it in 1967 in Japan2. The highest incidence of kDa continues to be reported among Asian children, with an incidence rate of 264.8 per 100 000 population aged 0–4 years as per Japan's latest nationwide survey3. In Africa, the true incidence is unknown but several case reports have been published. A 2016 paper by Gorrab et al.4 found that the annualized incidence rate of kDa in the Maghreb children living in Quebec (18.49/year/100 000 children under 5 years of age) was 4–12 times higher than reported in their countries of origin- Tunisia, Morocco, and Algeria (0.95, 4.52, and 3.15, respectively) suggesting a likelihood of under-diagnosis. This case series sought to highlight the characteristics, presentation, and management of patients diagnosed with kDa in a tertiary hospital in Kenya. Methods This was a retrospective cross-sectional study carried out by reviewing the charts of all the patients with a discharge diagnosis of kDa from January 2013 to December 2017 at the Aga Khan University Hospital, Nairobi. Their demographics, presentation, diagnostic work-up, and management are reported. Analysis was done by descriptive statistics using the Microsoft Excel 2016 Application. Results A total of 15 cases were identified and the patient characteristics and presentation are as tabulated below: Characteristic.  n (%).  Age (mean+/-SD, range, years)   2+/-1.5 (0.3-5.7)  Sex—Males   8 (53.3)  Duration of fever at diagnosis (mean +/-SD, range, days)   6.8+/-3.4 (2-13)  Incomplete KD   7 (46.7)  Clinical Features: Fever   15 (100)  Oral Changes   15 (100)  Extremity changes   12 (80)  Cervical lymphadenopathy   9 (60)  Non-exudative conjunctivitis   8 (53.3)  Characteristic.  n (%).  Age (mean+/-SD, range, years)   2+/-1.5 (0.3-5.7)  Sex—Males   8 (53.3)  Duration of fever at diagnosis (mean +/-SD, range, days)   6.8+/-3.4 (2-13)  Incomplete KD   7 (46.7)  Clinical Features: Fever   15 (100)  Oral Changes   15 (100)  Extremity changes   12 (80)  Cervical lymphadenopathy   9 (60)  Non-exudative conjunctivitis   8 (53.3)  Open in new tab Characteristic.  n (%).  Age (mean+/-SD, range, years)   2+/-1.5 (0.3-5.7)  Sex—Males   8 (53.3)  Duration of fever at diagnosis (mean +/-SD, range, days)   6.8+/-3.4 (2-13)  Incomplete KD   7 (46.7)  Clinical Features: Fever   15 (100)  Oral Changes   15 (100)  Extremity changes   12 (80)  Cervical lymphadenopathy   9 (60)  Non-exudative conjunctivitis   8 (53.3)  Characteristic.  n (%).  Age (mean+/-SD, range, years)   2+/-1.5 (0.3-5.7)  Sex—Males   8 (53.3)  Duration of fever at diagnosis (mean +/-SD, range, days)   6.8+/-3.4 (2-13)  Incomplete KD   7 (46.7)  Clinical Features: Fever   15 (100)  Oral Changes   15 (100)  Extremity changes   12 (80)  Cervical lymphadenopathy   9 (60)  Non-exudative conjunctivitis   8 (53.3)  Open in new tab In addition to elevated inflammatory markers (C reactive protein and/or Erythrocyte Sedimentation Rate), a significant number of the patients also had sterile pyuria (9/9), hypoalbuminemia (8/10), thrombocytosis (8/15), and anaemia (11/15). Nine out of eleven had negative blood cultures. Fourteen out of the fifteen patients had echocardiograms done during admission. Only one patient was found to have abnormal findings of bilaterally dilated coronaries arteries. Five patients had at least one documented repeat echocardiogram. Fourteen patients received Intravenous Immunoglobulin (IVIG), with 13 of them responding to treatment. No adverse effects were reported after treatment. One patient did not improve and needed a second dose of IVIG and intravenous methylprednisone (30 mg/kg). Fourteen patients received aspirin but dosing varied from high (80–90 mg/kg/day) to moderate (30–50 mg/kg/day) to low dose (3 mg/kg/day). One patient on high-dose aspirin was noted to have developed symptoms consistent with aspirin-induced bronchospasm and was changed to low dose. Conclusion This case series highlights the presence of kDa in the Kenyan pediatric population with patient characteristics similar to what is reported globally. Diagnosis was made after a mean of about 7 days, possibly due to low awareness of the disease among healthcare professionals. Management with IVIG in most cases was successful but more guidance is needed around the use of steroids and the dosing of aspirin. [ABSTRACT FROM AUTHOR]

Background We explore the spatial distribution of comorbidity with trachoma and potentially visual-impairing non-communicable diseases (NCDs) and their risk factors among Kenyan pastoralists. Methods Using a cross-sectional study design, we recruited and clinically examined 262 study participants for NCDs (hypertension or diabetes) and trachoma using the World Health Organization grading system. Network models estimated interactions and risks linked with trachoma and NCDs while the Poisson point process determined their spatial distribution. Results Of the 262 participants, 140 (53%) had trachoma, with >71% of these cases identified among females and those >60 y of age. A total of 36 trachoma cases co-occurred with hypertension (26%) and diabetes (0.01%). NCDs were frequent among those with recurring trachoma (21%) and trachomatous trichiasis (14.3%). Trachoma and NCDs clustered together in <1 km distances (R=0.18, p=0.02). In network analysis, age was strongly associated with trachoma and NCDs. Trachoma was linked with geographic location while diabetes was linked with water source distances. Education level became the central risk factor. Conclusions We demonstrate a twin trachoma–NCD burden that is higher among elderly pastoralists in southern Kenya. Attenuating adverse population-level visual impairment, including integrating the trachoma SAFE strategy with NCD comprehensive care, amplifies the benefits from economies of scale, accelerating realization of Sustainable Development Goal 3 and universal health coverage in hard-to-reach areas. [ABSTRACT FROM AUTHOR]

Trachoma, a disease caused by Chlamydia trachomatis , is the leading infectious cause of blindness. To fight it, endemic East African countries adopted the World Health Organization's SAFE Strategy, targeting surgery, antibiotics through mass drug administration (MDA), facial cleanliness and environmental improvement. Trachoma persists among nomadic communities along the Kenya–Uganda and Kenya–Tanzania borders. To address this, Kenya, Tanzania and Uganda launched synchronized MDA campaigns, simultaneously treating populations across borders. Successes included joint planning, community involvement and intergovernmental cooperation, although challenges remained in resourcing MDA cross-border focal points and in addressing coverage and funding. Novel strategies like synchronized joint cross-border MDA with community engagement are vital for sustainable trachoma elimination in these nomadic settings. [ABSTRACT FROM AUTHOR]

Background We explored reasons for continuing higher-than-anticipated prevalence of trachomatous trichiasis (TT) unknown to the health system in population-based prevalence surveys in evaluation units where full geographical coverage of TT case finding was reported. Methods A mixed-methods study in Ethiopia, Kenya, Nigeria and Tanzania was conducted. We compared data from clinical examination, campaign documentation and interviews with original trachoma impact survey (TIS) results. Results Of 169 TT cases identified by TIS teams, 130 (77%) were examined in this study. Of those, 90 (69%) were a match (both TIS and study teams agreed on TT classification) and 40 (31%) were a mismatch. Of the 40 mismatches, 22 (55%) were identified as unknown to the health system by the study team but as known to the health system by the TIS team; 12 (30%) were identified as not having TT by the study team but as having TT by the TIS team; and six (15%) were identified as unknown to the health system in the TIS team but as known to the health system by the study team based on documentation reviewed. Conclusions Incorrectly reported geographical coverage of case-finding activities, and discrepancies in TT status between TIS results and more detailed assessments, are the key reasons identified for continuing high TT prevalence. [ABSTRACT FROM AUTHOR]

High-quality data are essential to monitor and evaluate community health worker (CHW) programmes in low- and middle-income countries striving towards universal health coverage. This mixed-methods study was conducted in two purposively selected districts in Kenya (where volunteers collect data) and two in Malawi (where health surveillance assistants are a paid cadre). We calculated data verification ratios to quantify reporting consistency for selected health indicators over 3 months across 339 registers and 72 summary reports. These indicators are related to antenatal care, skilled delivery, immunization, growth monitoring and nutrition in Kenya; new cases, danger signs, drug stock-outs and under-five mortality in Malawi. We used qualitative methods to explore perceptions of data quality with 52 CHWs in Kenya, 83 CHWs in Malawi and 36 key informants. We analysed these data using a framework approach assisted by NVivo11. We found that only 15% of data were reported consistently between CHWs and their supervisors in both contexts. We found remarkable similarities in our qualitative data in Kenya and Malawi. Barriers to data quality mirrored those previously reported elsewhere including unavailability of data collection and reporting tools; inadequate training and supervision; lack of quality control mechanisms; and inadequate register completion. In addition, we found that CHWs experienced tensions at the interface between the formal health system and the communities they served, mediated by the social and cultural expectations of their role. These issues affected data quality in both contexts with reports of difficulties in negotiating gender norms leading to skipping sensitive questions when completing registers; fabrication of data; lack of trust in the data; and limited use of data for decision-making. While routine systems need strengthening, these more nuanced issues also need addressing. This is backed up by our finding of the high value placed on supportive supervision as an enabler of data quality. [ABSTRACT FROM AUTHOR]

This paper examines community-level association between exposure to the reproductive health vouchers programme in Kenya and utilization of services. The data are from a household survey conducted among 2527 women (15–49 years) from voucher and comparable non-voucher sites. Analysis entails cross-tabulations with Chi-square tests and significant tests of proportions as well as estimation of multi-level logit models to predict service utilization by exposure to the programme. The results show that for births occurring after the voucher programme began, women from communities that had been exposed to the programme since 2006 were significantly more likely to have delivered at a health facility and to have received skilled care during delivery compared with those from communities that had not been exposed to the programme at all. There were, however, no significant differences in the timing of first trimester utilization of antenatal care (ANC) and making four or more ANC visits by exposure to the programme. In addition, poor women were significantly less likely to have used safe motherhood services (health facility delivery, skilled delivery care and postnatal care) compared with their non-poor counterparts regardless of exposure to the programme. Nonetheless, a significantly higher proportion of poor women from communities that had been exposed to the programme since 2006 used the services compared with their poor counterparts from communities that had not been exposed to the programme at all. The findings suggest that the programme is associated with increased health facility deliveries and skilled delivery care especially among poor women. However, it has had limited community-level impact on the first trimester timing of antenatal care use and making four or more visits, which remain a challenge despite the high proportion of women in the country that make at least one antenatal care visit during pregnancy. [ABSTRACT FROM PUBLISHER]

Background Recruitment and retention of health workers is a major concern. Policy initiatives emphasize financial incentives, despite mixed evidence of their effectiveness. Qualitative studies suggest that nurses especially may be more driven by altruistic motivations, but quantitative research has overlooked such values. This paper adds to the literature through characterizing the nature and determinants of nurses’ altruism, based on a cross-country quantitative study. Methods An experimental ‘dictator game’ was undertaken with 1064 final year nursing students in Kenya, South Africa and Thailand between April 2007 and July 2008. This presents participants with a real financial endowment to split between themselves and another student, a patient or a poor person. Giving a greater share of this financial endowment to the other person is interpreted as reflecting greater altruism. Results Nursing students gave over 30% of their initial endowment to others (compared with 10% in similar experiments undertaken in other samples). Respondents in all three countries showed greater generosity to patients and the poor than to fellow students. Conclusions Consideration needs to be given to how to appeal to altruistic values as an alternative strategy to encourage nurses to enter the profession and remain, such as designing recruitment strategies to increase recruitment of altruistic individuals who are more likely to remain in the profession. [ABSTRACT FROM PUBLISHER]

This paper uses data from a maternal health study carried out in 2006 in two slums of Nairobi, Kenya, to: describe perceptions of access to and quality of care among women living in informal settlements of Nairobi, Kenya; quantify the effects of women's perceived quality of, and access to, care on the utilization of delivery services; and draw policy implications regarding the delivery of maternal health services to the urban poor. Based on the results of the facility survey, all health facilities were classified as ‘appropriate’ or ‘inappropriate’. The research was based on the premise that despite the poor quality of these maternal health facilities, their responsiveness to the socio-cultural and economic sensitivities of women would result in good perceptions and higher utilization by women.Our results show a pattern of women's good perceptions in terms of access to, and quality of, health care provided by the privately owned, sub-standard and often unlicensed clinics and maternity homes located within their communities. In the multivariate model, the association between women's perceptions of access to and quality of care, and delivery at these ‘inappropriate’ facilities remained strong, graded and in the expected direction.Women from the study area are seldom able to reach not-for-profit private providers of maternal health care services like missionary and non-governmental organization (NGO) clinics and hospitals. Against the backdrop of challenges faced by the public sector in health care provision, we recommend that the government should harness the potential of private clinics operating in urban, resource-deprived settings. First, the government should regulate private health facilities operating in urban slum settlements to ensure that the services they offer meet the acceptable minimum standards of obstetric care. Second, ‘good’ facilities should be given technical support and supplied with drugs and equipment. [ABSTRACT FROM PUBLISHER]

It is common in longitudinal studies for scheduled visits to be accompanied by as-needed visits due to medical events occurring between scheduled visits. If the timing of these as-needed visits is related to factors that are associated with the outcome but are not among the regression model covariates, naively including these as-needed visits in the model yields biased estimates. In this paper, the authors illustrate and discuss the key issues pertaining to inverse intensity rate ratio (IIRR)-weighted generalized estimating equations (GEE) methods in the context of a study of Kenyan mothers infected with human immunodeficiency virus type 1 (1999–2005). The authors estimated prevalences and prevalence ratios for morbid conditions affecting the women during a 1-year postpartum follow-up period. Of the 484 women under study, 62% had at least 1 as-needed visit. Use of a standard GEE model including both scheduled and unscheduled visits predicted a pneumonia prevalence of 2.9% (95% confidence interval: 2.3%, 3.5%), while use of the IIRR-weighted GEE predicted a prevalence of 1.5% (95% confidence interval: 1.2%, 1.8%). The estimate obtained using the IIRR-weighted GEE approach was compatible with estimates derived using scheduled visits only. These results highlight the importance of properly accounting for informative follow-up in these studies. [ABSTRACT FROM PUBLISHER]

The article examines the development of socialism in Kenya in the 1960s. The author explores the socioeconomic change that occurred during this time and discusses factors that proved to be influential in the country's development of African Socialism. Sessional Paper No. 10 from 1965, produced by Kenya's Ministry of Economic Planning and Development, coined this phrase and outlined the economic and social change the country envisioned. The author also explores the impact that political and economic freedom had on Kenya and the role that Cold War politics had on Kenya's development process.

In order to complement ongoing current empirical research, this article draws wider lessons from the crisis that grew out of the disputed Kenyan presidential election of December 2007. Looking beyond the immediate trigger for the subsequent violence - namely, the election itself-the paper instead locates the roots of the crisis within three historical trends: elite fragmentation, political liberalization, and state informalization. The origins of each can be traced to the style of rule employed by Daniel arap Moi. Even though his first government of 2002-5 perpetuated these trends, President Mwai Kibaki failed to recognize their implications for national unity and the exercise of power in 2007. The article then addresses the sequencing debate within the literature on democratization, identifying the lessons that can be taken from the Kenyan case for other states. Kenya has shown again that political liberalization is a high-risk activity that can produce unintended side-effects. Drawing on examples from other African states, we argue that the processes of democratization and reform can be undertaken simultaneously, but that this twin-tracked approach requires institutional reforms not yet undertaken by a large number of African polities. [ABSTRACT FROM AUTHOR]

Home management is a very common approach to the treatment of illnesses such as malaria, acute respiratory infections, tuberculosis, diarrhoea and sexually transmitted infections, frequently through over-the-counter purchase of drugs from shops. Inappropriate drugs and doses are often obtained, but interventions to improve treatment quality are rare. An educational programme for general shopkeepers and communities in Kilifi District, rural Kenya was associated with major improvements in the use of over-the-counter anti-malarial drugs for childhood fevers. The two main components were workshop training for drug retailers and community information activities, with impact maintained through on-going refresher training, monitoring and community mobilization. This paper presents the cost and cost-effectiveness of the programme in terms of additional appropriately treated cases, evaluating both its measured cost-effectiveness in the first area of implementation (early implementation phase) and the estimated cost-effectiveness of the programme recommended for district-level implementation (recommended district programme).The proportion of shop-treated childhood fevers receiving an adequate amount of a recommended antimalarial rose from 2% to 15% in the early implementation phase, at an economic cost of $4.00 per additional appropriately treated case (2000 US$). If the same impact were achieved through the recommended district programme, the economic cost per additional appropriately treated case would be $0.84, varying between $0.37 and $1.36 in the sensitivity analysis. As with most educational approaches, the programme carries a relatively high initial financial cost, of $11 477 ($0.02 per capita) for the development phase and $81450 ($0.17 per capita) for the set up year, which would be particularly suitable for donor funding, while the annual costs of $18 129 ($0.04 per capita) thereafter could be contained within the budget of a typical District.To reach the Abuja target of 60% of those suffering from malaria in sub-Saharan Africa having access to affordable and appropriate treatment within 24 hours, improvements in community-based malaria treatment are urgently required. From these results, policymakers can estimate costs for district-scale shopkeeper training programmes, and will be able to assess their relative cost-effectiveness as comparable evaluations become available from home management interventions in the future. Extrapolation of the results using a simple decision tree model to estimate the cost per DALY averted indicates that the intervention is likely to be considered highly cost-effective in comparison with standard benchmarks for interventions in low-income countries. [ABSTRACT FROM AUTHOR]

This paper examines changes in children's concepts of health and illness following an action-oriented health education intervention in Bondo district of Western Kenya. The study is a feasibility study exploring a specific educational approach, and it combines elements of health education research and anthropological research. Forty primary schoolchildren aged 10–15 years of age underwent a 2-month intervention and were thereafter enrolled as health communicators in a longitudinal study for an additional period of 12 months. Data were collected before, during and after the intervention using in-depth interviews and the draw-and-write technique. Students' actions and their active participation were key elements in the intervention. Although the intervention from the beginning focused on two specific diseases (malaria and diarrhea), the students were involved in developing their own ideas and visions about which changes to make, which actions to carry out and which target groups to approach. Data showed that children had acquired new concepts of health, some of which incorporated elements of the old ones. More action-oriented health concepts were identified and a general change from an external locus of control towards an internal locus of control was found. The study concludes that students can modify and broaden their concepts of health and illness through action-oriented health education. Key factors are the development of students' ownership through active and participatory teaching and learning approaches. [ABSTRACT FROM AUTHOR]

Malaria remains a major health problem in Africa. One preventative strategy currently advocated is the use of bednets, preferably treated with insecticide. Many approaches to bednet delivery have been adopted in Kenya, including an employer-based malaria control strategy (EBMC). The cost and sustainability of this approach have not previously been assessed. This paper presents the financial cost (cash expenditure) of the EBMC programme implemented in the Coastal and Western regions of Kenya by the African Medical and Research Foundation (AMREF) between April 1998 and February 2002. Getting a bednet and insecticide to an employee was estimated to cost the provider US$15.8. This could be reduced by US$0.5 if the remaining stocks were liquidated and by an additional US$1.3 if the salvage of capital items is considered. The venture of distributing bednets to employees through the programme proved lucrative to organized community groups (OCGs), for they made between 24 and 29% gross profit from the nets they sold. Consequently, OCGs in nine of the 13 companies involved had retained enough funds from which they could buy and sell bednets without further donor financial support, and this portrays some elements of a sustainable supply system. [ABSTRACT FROM AUTHOR]

This paper investigates individual motives to participate in rotating savings and credit associations (roscas). Detailed evidence from roscas in a Kenyan slum (Nairobi) suggests that most roscas are predominantly composed of women, particularly those living in a couple and earning an independent income. We propose an explanation of this based on conflictual interactions within the household. Participation in a rosca is a strategy a wife employs to protect her savings against claims by her husband for immediate consumption. The empirical implications of the model are then tested using the data collected in Kenya. [ABSTRACT FROM AUTHOR]

The need to bolster primary health care (PHC) to achieve the Sustainable Development Goal (SDG) targets for health is well recognized. In Eastern and Southern Africa, where governments have progressively decentralized health decision-making, health management is critical to PHC performance. While investments in health management capacity are important, so is improving the environment in which managers operate. Governance arrangements, management systems and power dynamics of actors can have a significant influence on health managers' ability to improve PHC access and quality. We conducted a problem-driven political economy analysis (PEA) in Kenya, Malawi and Uganda to explore local decision-making environments and how they affect management and governance practices for health. This PEA used document review and key informant interviews (N  = 112) with government actors, development partners and civil societies in three districts or counties in each country (N  = 9). We found that while decentralization should improve PHC by supporting better decisions in line with local priorities from community input, it has been accompanied by thick bureaucracy, path-dependent and underfunded budgets that result in trade-offs and unfulfilled plans, management support systems that are less aligned to local priorities, weak accountability between local government and development partners, uneven community engagement and insufficient public administration capacity to negotiate these challenges. Emergent findings suggest that coronavirus disease 2019 (COVID-19) not only resulted in greater pressures on health teams and budgets but also improved relations with central government related to better communication and flexible funding, offering some lessons. Without addressing the disconnection between the vision for decentralization and the reality of health managers mired in unhelpful processes and politics, delivering on PHC and universal health coverage goals and the SDG agenda will remain out of reach. [ABSTRACT FROM AUTHOR]

Background Coronavirus disease 2019 (COVID-19), declared a global pandemic by the World Health Organization (WHO), is a severe acute respiratory disease. The Kenyan Ministry of Health (MoH) put in place measures that included mandatory face masking, hand and cough hygiene and social and physical distancing to reduce disease transmission and increase prevention efforts. The primary objective of this study was to determine how sociodemographic characteristics affect knowledge and practice of the above measures. Methods A cross-sectional study was conducted to assess water, sanitation and hygiene practices for the prevention and control of COVID-19 in Kilifi and Mombasa Counties, Kenya. Data collection was accomplished through a mobile data collection tool. Principal component analysis was used to create a wealth index using data on asset ownership and housing characteristics. Bloom cut-off points of 80–100%, 60–79% and ≤59% were used to determine knowledge and practice. Results Of the 612 households, 339 (55.4%) were from Kilifi County and 273 (44.6%) were from Mombasa County. A total of 431 (70.4%) were female and the mean age of the household members was 38.2±14.8 y. Almost all (99.2%) respondents were aware of COVID-19, with 60% knowing prevention, symptoms and persons at a higher risk of contracting the virus. Females had the highest knowledge of COVID-19 and were likely to practice prevention and control measures, unlike males. Age was significant (p<0.05) with knowledge and practice. Conclusions The sociodemographic characteristics of populations play a key role in behavioural aspects as far as prevention and control of COVID-19 are concerned. There is a need for partnerships between the MoH and county governments to put in place a multisectoral community approach to advance feasible behavioural interventions among targeted populations towards combating the spread of COVID-19. [ABSTRACT FROM AUTHOR]

Discusses news and events concerning biologists and the biological sciences. 'And Then the Rains Came,' a documentary about Kenya's endangered animals; Richard C. Adelman who was elected the president of the Gerontological Society of America; Grant awarded to the Missouri Botanical Garden; Harvey Price who announced he would leave his position as director of the Industrial Biotechnology Association. INSET: Natural history on the air.

Public Financial Management (PFM) processes are a driver of health system efficiency. PFM happens within the budget cycle which entails budget formulation, execution and accountability. At the budget execution phase, budgets are implemented by spending as planned to generate a desired output or outcome. Understanding how the budget execution processes influence the use of inputs, and the outcomes that result is important for maximizing efficiency. This study sought to explain how the budget execution processes influence the efficiency of health systems, an area that is understudied, using a case study of county health systems in Kenya. We conducted a concurrent mixed methods case study using counties classified as relatively efficient (n=2) and relatively inefficient (n=2). We developed a conceptual framework from a literature review to guide the development of tools and analysis. We collected qualitative data through document reviews, and in-depth interviews (n=70) with actors from health and finance sectors at the national and county level. We collected quantitative data from secondary sources, including budgets and budget reports. We analyzed qualitative data using the thematic approach and carried out descriptive analyses on quantitative data. The budget execution processes within counties in Kenya were characterized by poor budget credibility, cash disbursement delays, limited provider autonomy, and poor procurement practices. These challenges were linked to an inappropriate input mix that compromised the capacity of county health systems to deliver healthcare services, misalignment between county health needs and the use of resources, reduced staff motivation and productivity, procurement inefficiencies, and reduced county accountability for finances and performance. The efficiency of county health systems in Kenya can be enhanced by improving budget credibility, cash disbursement processes, procurement processes, and provider autonomy. [ABSTRACT FROM AUTHOR]

This prospective study of 39 women living with human immunodeficiency virus (HIV) on antiretroviral therapy in Western Kenya aimed to quantify genital tract HIV-1 RNA (GT-HIV RNA) shedding before and after cryotherapy for cervical intraepithelial neoplasia. Most GT-HIV RNA shedding was detected precryotherapy, suggesting that cryotherapy was not the primary cause of shedding. [ABSTRACT FROM AUTHOR]

Global financing for the HIV response has reached unprecedented levels in recent years. Over US$10 billion were mobilized in 2007, an effort credited with saving the lives of millions of people living with HIV (PLHIV). A relatively unexamined aspect of the global HIV response is the role of the private sector in financing HIV/AIDS services. As the nature of the response evolves from emergency relief to long-term sustainability, understanding current and potential contributions from the private sector is critical. This paper examines trends in private sector financing, management and resource consumption related to HIV/AIDS in five sub-Saharan African countries, with a particular emphasis on the effects of recently scaled-up donor funding on private sector contributions. We analysed National Health Accounts HIV/AIDS subaccount data for Kenya, Malawi, Rwanda, Tanzania and Zambia between 2002 and 2006. HIV subaccounts provide comparable data on the flow of HIV/AIDS funding from source to use. Findings indicate that private sector contributions decreased in all countries except Tanzania. With regards to managing HIV/AIDS funds, non-governmental organizations are increasingly controlling the largest share of resources relative to other stakeholders, whereas private for-profit entities are managing fewer HIV/AIDS resources since the donor influx. The majority of HIV/AIDS funds were spent in the public sector, although a considerable amount was spent at private facilities, largely fuelled by out-of-pocket (OOP) payments. On the whole, OOP spending by PLHIV decreased over the 4-year period, with the exception of Malawi, demonstrating that PLHIV have increased access to free or subsidized HIV/AIDS services. Our findings suggest that the influx of donor funding has led to decreased private contributions for HIV/AIDS. The reduction in private sector investment and engagement raises concerns about the sustainability of HIV/AIDS programmes over the long term, particularly in light of current global economic crisis and emerging competing priorities. [ABSTRACT FROM AUTHOR]

The article comments on the paper "Respiratory Syncytial Virus Infection and Disease in Infants and Young Children Studied From Birth in Kilifi District, Kenya," by J. D. Nokes and colleagues, published within this issue. Findings of this paper suggest that respiratory viral infections is a significant cause of severe respiratory infections among children in a developing country like Kenya. The authors discuss the need to conduct active community surveillance to determine this disease's burden.

Third, the authors did not appropriately disentangle research costs from intervention costs in analysing data from the Zambia randomized controlled trial. We recognize and appreciate the vast undertaking that TorresReudaetal. has taken on with this analysis and reiterate that we believe costing analyses of interventions are vital for scaling up effective VAWG interventions. Not all costs should be treated equally: Commentary on the article 'What will it cost to prevent violence against women and girls in low- and middle-income countries?. [Extracted from the article]

Background Cataract is a major cause of visual impairment globally, affecting 15.2 million people who are blind, and another 78.8 million who have moderate or severe visual impairment. This study was designed to explore factors that influence the uptake of surgery offered to patients with operable cataract in a free-of-charge, community-based eye health programme. Methods Focus group discussions and in-depth interviews were conducted with patients and healthcare providers in rural Zambia, Kenya and Uganda during 2018–2019. We identified participants using purposive sampling. Thematic analysis was conducted using a combination of an inductive and deductive team-based approach. Results Participants consisted of 131 healthcare providers and 294 patients. Two-thirds of patients had been operated on for cataract. Two major themes emerged: (1) surgery enablers, including a desire to regain control of their lives, the positive testimonies of others, family support, as well as free surgery, medication and food; and (2) barriers to surgery, including cultural and social factors, as well as the inadequacies of the healthcare delivery system. Conclusions Cultural, social and health system realities impact decisions made by patients about cataract surgery uptake. This study highlights the importance of demand segmentation and improving the quality of services, based on patients' expectations and needs, as strategies for increasing cataract surgery uptake. [ABSTRACT FROM AUTHOR]

Cohort effects, reflecting early adversity or advantage, have persisting consequences for growth, reproductive onset, longevity, and lifetime reproductive success. In species with prolonged life histories, cohort effects may establish variation in age-sex structures, while social structure may buffer individuals against early adversity. Using periods of significant ecological adversity, we examined cohort effects for male and female elephants (Loxodonta africana) over almost 50 years in Amboseli, Kenya. Mortality spiked during severe droughts with highest mortality among calves under 2 years and females over 40 years. Deaths of oldest females resulted in social disruption via matriarch turnover, with potential impacts on resource acquisition for survivors. We predicted that survivors of high mortality and social challenges would have altered life-history trajectories, with later age at first reproduction and reduced age-specific fertility for females and slow transitions to independence and late-onset of potential mating or musth among males. Contrary to expectations, there were no persisting early drought effects on female age at first conception while matriarch loss around puberty accelerated reproductive onset. Experience of an early life drought did not influence age-specific reproductive rates once females commenced reproduction. Males who survived an early drought exhibited complex consequences: male age at family independence was later with larger peer cohort size, but earlier with drought in year of independence (13.9 vs 14.6 years). Early drought had no effect on age at first musth, but male reproductive onset was weakly associated with the number of peers (negative) and age at independence (positive). [ABSTRACT FROM AUTHOR]

To better understand the wide variation of performance among county health systems in Kenya, this study investigated their performance determinants. We selected five counties with varied performance and examined their performance across five domains containing 10 thematic areas. We conducted a stakeholder analysis, consisting of focus group discussions and key informant interviews, and administered a quantitative survey to quantify the magnitude of inefficiency. The study found that a shortage of funding was one of the most common complaints from counties, leading to inefficiency in the health system. Another major reason for inefficiencies was the delay in disbursing funding to health facilities, which affected the procurement of medical supplies and commodities essential for delivering healthcare to the population. In addition, lack of autonomy in procuring commodities and equipment was repeatedly mentioned as a barrier to delivering quality health services. Other reported common concerns contributing to the performance of county health systems were the lack of lab tests and equipment, low willingness to join health insurance, rigid procurement policies and lengthy procurement process, lack of motivation and incentives for service delivery, and poor economic status. Despite the common concerns among the five counties, they differed in some schematic areas, such as the county's commitment to health and community mobilization. In summary, this study suggests various factors that determine county health system performance. Given the multifaceted nature of inefficiency drivers, it is necessary to adopt a holistic approach to address the causes of inefficiencies and improve the county health systems. [ABSTRACT FROM AUTHOR]

We examined the impact of coronavirus disease (COVID) mitigation, supply and distribution interruptions on the delivery of long-lasting insecticide-treated nets (LLINs) in Western Kenya. The median monthly distribution of LLINs declined during COVID mitigation strategies (March–July 2020) and during the health worker strikes (December 2020–February 2021). Recovery periods followed initial declines, indicative of a 'catching up' on missed routine distribution. Mass community campaigns were delayed by 10 months. These observations offer encouragement for routine net distribution resilience, but complete interruptions of planned mass distributions require alternate strategies during pandemics. [ABSTRACT FROM AUTHOR]

It is argued that ethnic competition, triggers for ethnic mobilization, and political institutions together affect changes in government-imposed political and economic restrictions on ethnic groups worldwide. Due to the fact that the only existing comparative data set on ethnic discrimination, produced by the Minorities at Risk project, uses discrimination as a criterion for including ethnic groups, a new data set of 620 additional groups has been created to predict the selection process through a full-information, maximum-likelihood Heckman probit model, but selection bias is found not to affect the results. Discrimination is modeled as a dynamic Markov process, and central and regional government institutions, economic conditions, and minority group characteristics are found to influence the initiation and continuation of discriminatory policies. [ABSTRACT FROM AUTHOR]

In a large-scale randomised experiment implemented with Kenya's Electoral Commission, text messages intended to mobilise voters boosted electoral participation. However, the messages also decreased trust in electoral institutions after the election. This decrease was stronger for individuals on the losing side and in areas that experienced election-related violence. We hypothesise that the mobilisation campaign backfired because the Electoral Commission promised a transparent and orderly electoral process but failed to deliver on these expectations. Several potential mechanisms account for the intervention's unexpected effects, including a simple model where signalling capacity via mobilisation messages can negatively affect beliefs about election fairness. [ABSTRACT FROM AUTHOR]