Background Drug and substance abuse has adverse health effects and a substantial economic burden ... more Background Drug and substance abuse has adverse health effects and a substantial economic burden to the global economies and at the household level. There is, however, limited data on socioeconomic disparities in the update of the substance of abuse in low-to-middle income countries such as Kenya. This study aimed to assess the socioeconomic disparities among drugs and substances in Murang'a county of central Kenya. Method The study design was cross-sectional, and data collection was conducted between November and December 2017. A total of 449 households with at least one person who has experienced substance abuse were sampled from four purposively selected sub-locations of Murang' a County. Household heads answered questions on house characteristics and as an abuser or on behalf of abusers in their households. Structured questionnaires were used to collect data on types of drugs used, economic burden, and gender roles at the household level. Household socioeconomic status (SES) was established (low, middle, and high SES) using principal component analysis (PCA) from a set of household assets and characteristics. Bivariable logistic regression analysis was used to assess the association between SES, gender, and other factors on the uptake of drugs and substance abuse. Results Individuals in higher SES were more likely to use cigarettes (OR = 2.13; 95%CI = 1.25-3.61, p = 0.005) or piped tobacco (OR = 11.37; 95% CI, 2.55-50.8; p-value = 0.001) than those in low SES. The wealthier individuals were less likely to use legal alcohol (OR = 0.39; 95%CI = 0.21-0.71, p = 0.002) than the poorest individuals. The use of prescription drugs did not vary with SES. A comparison of the median amount of money spent on acquiring drugs showed that richer individuals spent a significantly lower amount than the poorest individuals (USD 9.71 vs. Ksh 14.56, p = 0.031). Deaths related to drugs and substance abuse were more likely to occur in middle SES than amongst the poorest households (OR = 2.96; 95%CI = 1.03-8.45, p = 0.042). Conclusion Socioeconomic disparities exist in the use of drugs and substance abuse. Low-income individuals are at a higher risk of abuse, expenditures and even death. Strategies to reduce drugs and substance abuse must address socioeconomic disparities through targeted approaches to individuals in low-income groups.
Background: Drug and substance abuse has adverse health effects and a substantial economic burden... more Background: Drug and substance abuse has adverse health effects and a substantial economic burden to the global economies and at the household level. There is, however, limited data on socio-economic disparities in drugs and substance abuse in low-to-middle income countries such as Kenya. This study aimed to assess the socio-economic disparities in Murang’a county of central Kenya.Method: The study design was cross-sectional, and data collection was conducted between November and December 2017. A total of 449 households with at least one person who uses any drug or substance of abuse were randomly sampled from 4 purposively selected sub-locations of Murang’ a County. Structured questionnaires were used to collect data on types of drugs used, economic burden, and gender roles at the household level. Household socio-economic status (SES) was established (low, middle, and high SES ) using principal component analysis f(PCA) from a set of household assets and characteristics. Multivaria...
Background Malaria-endemic countries distribute long-lasting insecticidal nets (LLINs) through co... more Background Malaria-endemic countries distribute long-lasting insecticidal nets (LLINs) through combined channels with ambitious, universal coverage (UC) targets. Kenya has used eight channels with variable results. To inform national decision-makers, this two-arm study compares coverage (effects), costs, cost-effectiveness, and equity of two combinations of LLIN distribution channels in Kenya. Methods Two combinations of five delivery channels were compared as ‘intervention’ and ‘control’ arms. The intervention arm comprised four channels: community health volunteer (CHV), antenatal and child health clinics (ANCC), social marketing (SM) and commercial outlets (CO). The control arm consisted of the intervention arm channels except mass campaign (MC) replaced CHV. Primary analysis used random sample household survey data, service-provider costs, and voucher or LLIN distribution data to compare between-arm effects, costs, cost-effectiveness, and equity. Secondary analyses compared cost...
IntroductionAmid the rising number of people with non-communicable diseases (NCDs), Kenya has inv... more IntroductionAmid the rising number of people with non-communicable diseases (NCDs), Kenya has invested in strengthening primary care and in efforts to expand existing service delivery platforms to integrate NCD care. One such approach is the AMPATH (Academic Model Providing Access to Healthcare) model in western Kenya, which provides the platform for the Primary Health Integrated Care Project for Chronic Conditions (PIC4C), launched in 2018 to further strengthen primary care services for the prevention and control of hypertension, diabetes, breast and cervical cancer. This study seeks to understand how well PIC4C delivers on its intended aims and to inform and support scale up of the PIC4C model for integrated care for people with NCDs in Kenya.Methods and analysisThe study is guided by a conceptual framework on implementing, sustaining and spreading innovation in health service delivery. We use a multimethod design combining qualitative and quantitative approaches, involving: (1) i...
ABSTRACTBackgroundCase management of symptomatic COVID-19 patients is a key health system interve... more ABSTRACTBackgroundCase management of symptomatic COVID-19 patients is a key health system intervention. The Kenyan government embarked to fill capacity gaps in essential and advanced critical care needed for the management of severe and critical COVID-19. However, given scarce resources, gaps in both essential and advanced critical care persist. This study assessed the cost-effectiveness of investments in essential and advanced critical care to inform the prioritization of investment decisions.MethodsWe employed a decision tree model to assess the incremental cost-effectiveness of investment in essential care (EC) and investment in both essential and advanced critical care (EC+ACC) compared to current health care provision capacity (status quo) for COVID-19 patients in Kenya. We used a health system perspective, and an inpatient care episode time horizon. Cost data was obtained from primary empirical analysis while outcomes data was obtained from epidemiological model estimates. We ...
Policy makers in Africa need robust estimates of the current and future spread of SARS-CoV-2. Dat... more Policy makers in Africa need robust estimates of the current and future spread of SARS-CoV-2. Data suitable for this purpose are scant. We used national surveillance PCR test, serological survey and mobility data to develop and fit a county-specific transmission model for Kenya. We estimate that the SARS-CoV-2 pandemic peaked before the end of July 2020 in the major urban counties, with 34 41% of residents infected, and will peak elsewhere in the country within 2-3 months. Despite this penetration, reported severe cases and deaths are low. Our analysis suggests the COVID-19 disease burden in Kenya may be far less than initially feared. A similar scenario across sub-Saharan Africa would have implications for balancing the consequences of restrictions with those of COVID-19.
IntroductionCase management for COVID-19 patients is one of key interventions in country response... more IntroductionCase management for COVID-19 patients is one of key interventions in country responses to the pandemic. Countries need information on the costs of case management to inform resource mobilization, planning and budgeting, purchasing arrangements, and assessments of the cost-effectiveness of interventions. We estimated unit costs for COVID-19 case management for patients with asymptomatic, mild to moderate, severe, and critical COVID-19 disease in Kenya.MethodsWe estimated per patient per day unit costs of COVID-19 case management for patients that are asymptomatic and those that have mild to moderate, severe, and critical symptoms. For asymptomatic and mild to moderate patients, we estimated unit costs for home-based care and institutional (hospitals and isolation centers). We used an ingredients approach, adopted a health system perspective and patient episode of care as our time horizon. We obtained data on inputs and their quantities from COVID-19 case management guidel...
Supplemental material, Manuscript_Supplemental_Appendix.rjf_online_supp for The Costs of Implemen... more Supplemental material, Manuscript_Supplemental_Appendix.rjf_online_supp for The Costs of Implementing Vaccination With the RTS,S Malaria Vaccine in Five Sub-Saharan African Countries by Elisa Sicuri, Fadima Yaya Bocoum, Justice Nonvignon, Sergi Alonso, Bakar Fakih, George Bonsu, Simon Kariuki, Oscar Leeuwenkamp, Khatia Munguambe, Mwifadhi Mrisho, Vincent Were and Christophe Sauboin in MDM Policy & Practice
Dihydroartemisinin-piperaquine (DP) is a long-acting artemisinin combination treatment that provi... more Dihydroartemisinin-piperaquine (DP) is a long-acting artemisinin combination treatment that provides effective chemoprevention and has been proposed as an alternative antimalarial drug for intermittent preventive therapy in pregnancy (IPTp). Several pharmacokinetic studies have shown that dose adjustment may not be needed for the treatment of malaria in pregnancy with DP.
Background. The World Health Organization has recommended pilot implementation of a candidate vac... more Background. The World Health Organization has recommended pilot implementation of a candidate vaccine against malaria (RTS,S/AS01) in selected sub-Saharan African countries. This exploratory study aimed to estimate the costs of implementing RTS,S in Burkina Faso, Ghana, Kenya, Mozambique, and Tanzania. Methods. Key informants of the expanded program on immunization at all levels in each country were interviewed on the resources required for implementing RTS,S for routine vaccination. Unit prices were derived from the same sources or from international price lists. Incremental costs in 2015 US dollars were aggregated per fully vaccinated child (FVC). It was assumed the four vaccine doses were either all delivered at health facilities or the fourth dose was delivered in an outreach setting. Results. The costs per FVC ranged from US$25 (Burkina Faso) to US$37 (Kenya) assuming a vaccine price of US$5 per dose. Across countries, recurrent costs represented the largest share dominated by ...
Background To improve access to surgical care in rural Nicaragua, a collaboration was established... more Background To improve access to surgical care in rural Nicaragua, a collaboration was established between the Global Initiative for Children's Surgery (GICS), Operation Smile Nicaragua, and the Nicaragua Ministry of Health. Prior to implementation of the surgical programme Surgery for the People Nicaragua, our aim was to perform a baseline assessment of the Nicaraguan health system's capacity to provide safe surgical care in its rural zones. Methods In June and July 2017, a retrospective baseline evaluation of safe surgical care provision was performed at two rural district hospitals in Las Minas using the GICS Optimal Resources tool, the WHO/Program in Global Surgery & Social Change (PGSSC) Surgical Assessment tool, the World Federation of Societies of Anesthesiologists Assessment tool, and the PGSSC Qualitative Assessment tool. Main outcome measures were: surgical workforce density, surgical volume, perioperative mortality rates, level of infrastructure, access to essential medicines, and health system financing. Findings The surgical workforce density was six per 100 000 population, including one paediatric surgeon (the WHO target surgical workforce density is 20 per 100 000 population). The surgical volume was 1050 procedures per 100 000 population per year; less than 10% of the surgical volume was paediatric. Perioperative mortality rates were low but not routinely collected: range 0•12%-0•50%. There were major needs in infrastructure including: additional operating theatres; running water at one site; post-anaesthetic recovery room areas; and paediatric-specific surgical wards. There was adequate access to essential medications including oxygen, anaesthetics, and antibiotics. Care at the two district hospitals was free, and there were no recorded out-of-pocket expenses for surgical patients. Interpretation A major success of the Nicaraguan health system is free surgical care, protecting patients from catastrophic expenditure. However, to improve access to surgical care in rural Nicaragua, there is a need for investments in human resources, particularly in anaesthesia and paediatric providers. Furthermore, there is a need for monitoring and evaluation of key indicators including perioperative mortality and complication rates. Funding UBS Optimus Foundation.
Health inequality is a recognized barrier to achieving health-related development goals. Health-e... more Health inequality is a recognized barrier to achieving health-related development goals. Health-equality data are essential for evidence-based planning and assessing the effectiveness of initiatives to promote equity. Such data have been captured but have not always been analysed or used to manage programming. Health data were examined for microeconomic differences in malaria indices and associated malaria control initiatives in western Kenya. Data was analysed from a malaria cross-sectional survey conducted in July 2012 among 2719 people in 1063 households in Siaya County, Kenya. Demographic factors, history of fever, malaria parasitaemia, malaria medication usage, insecticide-treated net (ITN) use and expenditure on malaria medications were collected. A composite socioeconomic status score was created using multiple correspondence analyses (MCA) of household assets; households were classified into wealth quintiles and dichotomized into poorest (lowest 3 quintiles; 60%) or less-poo...
Most human Plasmodium infections in western Kenya are asymptomatic and are believed to contribute... more Most human Plasmodium infections in western Kenya are asymptomatic and are believed to contribute importantly to malaria transmission. Elimination of asymptomatic infections requires active treatment approaches, such as mass testing and treatment (MTaT) or mass drug administration (MDA), as infected persons do not seek care for their infection. Evaluations of community-based approaches that are designed to reduce malaria transmission require careful attention to study design to ensure that important effects can be measured accurately. This manuscript describes the study design and methodology of a cluster-randomized controlled trial to evaluate a MTaT approach for malaria transmission reduction in an area of high malaria transmission. Ten health facilities in western Kenya were purposively selected for inclusion. The communities within 3 km of each health facility were divided into three clusters of approximately equal population size. Two clusters around each health facility were r...
both overall and those considered specific to the antihypertensive drug. Perinatal outcomes studi... more both overall and those considered specific to the antihypertensive drug. Perinatal outcomes studied were fetal heart rate abnormalities, fetal and neonatal death, admission to the neonatal intensive care unit, and 5 minute Apgar score <7. Study quality was assessed and data were analyzed using a fixed effect model, with random effects modelling if heterogeneity was substantial. Seven randomized controlled trials involving 363 woman-infant pairs met the inclusion criteria. On primary analysis, oral nifedipine was associated with decreased risk of persistent hypertension (relative risk, 0.42; 95% confidence intervals, 0.18-0.96) and fewer maternal side effects (relative risk, 0.57; 95% confidence intervals, 0.35-0.94) compared with intravenous labetalol. However, following sensitivity analysis to explore the impact of study quality on effect size, the difference between drugs for persistent hypertension was no longer significant. No statistically significant differences were found for any of the other maternal or perinatal outcomes. The study concluded that oral nifedipine is as efficacious and safe as intravenous labetalol. Because of its ease of administration, it may have an edge in low resource settings. Although the authors recommend that larger studies be performed, they believe this meta-analysis is a useful comparative analysis of the safety and efficacy of oral nifedipine and intravenous labetalol for the treatment of severe hypertension in parturients.
Although anti-malarial medicines are free in Kenyan public health facilities, patients often seek... more Although anti-malarial medicines are free in Kenyan public health facilities, patients often seek treatment from private sector retail drug outlets. In mid-2010, the Affordable Medicines Facility-malaria (AMFm) was introduced to make quality-assured artemisinin-based combination therapy (ACT) accessible and affordable in private and public sectors. Private sector retail drug outlets stocking anti-malarial medications within a surveillance area of approximately 220,000 people in a malaria perennial high-transmission area in rural western Kenya were identified via a census in September 2013. A cross-sectional study was conducted in September-October 2013 to determine availability and price of anti-malarial medicines and malaria rapid diagnostic tests (RDTs) in drug outlets. A standardized questionnaire was administered to collect drug outlet and personnel characteristics and availability and price of anti-malarials and RDTs. Of 181 drug outlets identified, 179 (99 %) participated in t...
In 2007, the US Centers for Disease Control and Prevention partnered with local Kenyan institutio... more In 2007, the US Centers for Disease Control and Prevention partnered with local Kenyan institutions to implement the Nyando Integrated Child Health and Education Project, an effectiveness study that used social marketing and a community-based distribution program to promote the sale of Sprinkles and other health products. To describe monitoring of wholesale sales, household demand, promotional strategies, and perceived factors influencing Sprinkles sales among vendors. Ongoing quantitative and qualitative monitoring of Sprinkles sales began in May 2007 in 30 intervention villages. Data sources included baseline and follow-up cross-sectional surveys; office records of Sprinkles sales to vendors; biweekly household monitoring of Sprinkles use; and qualitative data collection, including vendor focus groups and key informant interviews. A total of 550 children aged 6 to 35 months were enrolled at baseline, and 451 were available at 12-month follow-up. During this period, nearly 160,000 ...
Monitoring local malaria transmission intensity is essential for planning evidence-based control ... more Monitoring local malaria transmission intensity is essential for planning evidence-based control strategies and evaluating their impact over time. Anti-malarial antibodies provide information on cumulative exposure and have proven useful, in areas where transmission has dropped to low sustained levels, for retrospectively reconstructing the timing and magnitude of transmission reduction. It is unclear whether serological markers are also informative in high transmission settings, where interventions may reduce transmission, but to a level where considerable exposure continues. This study was conducted through ongoing KEMRI and CDC collaboration. Asembo, in Western Kenya, is an area where intense malaria transmission was drastically reduced during a 1997-1999 community-randomized, controlled insecticide-treated net (ITN) trial. Two approaches were taken to reconstruct malaria transmission history during the period from 1994 to 2009. First, point measurements were calculated for serop...
Background: Exposure to household air pollutants released during cooking has been linked to numer... more Background: Exposure to household air pollutants released during cooking has been linked to numerous adverse health outcomes among residents of rural areas in low-income countries. Improved cookstoves are one of few available interventions, but achieving equity in cookstove access has been challenging. Therefore, innovative approaches are needed. To evaluate a project designed to motivate adoption of locally-produced, ceramic cookstoves (upesi jiko) in an impoverished, rural African population, we assessed the perceived benefits of the cookstoves (in monetary and time-savings terms), the rate of cookstove adoption, and the equity of adoption. Methods: The project was conducted in 60 rural Kenyan villages in 2008 and 2009. Baseline (n = 1250) and follow-up (n = 293) surveys and a stove-tracking database were analyzed. Results: At baseline, nearly all respondents used wood (95%) and firepits (99%) for cooking; 98% desired smoke reductions. Households with upesi jiko subsequently spent <100 Kenyan Shillings/week on firewood more often (40%) than households without upesi jiko (20%) (p = 0.0002). There were no significant differences in the presence of children <2 years of age in households using upesi jiko (48%) or three-stone stoves (49%) (p = 0.88); children 2-5 years of age were less common in households using upesi jiko versus three-stone stoves (46% and 69%, respectively) (p = 0.0001). Vendors installed 1,124 upesi jiko in 757 multi-family households in 18 months; 68% of these transactions involved incentives for vendors and purchasers. Relatively few (<10%) upesi jiko were installed in households of women in the youngest age quartile (<22 years) or among households in the poorest quintile. Conclusions: Our strategy of training of local vendors, appropriate incentives, and product integration effectively accelerated cookstove adoption into a large number of households. The strategy also created opportunities to reinforce health messages and promote cookstoves sales and installation. However, the project's overall success was diminished by inequitable and incomplete adoption by households with the lowest socioeconomic status and young children present. Additional evaluations of similar strategies will be needed to determine whether our strategy can be applied equitably elsewhere, and whether reductions in fuel use, household air pollution, and the incidence of respiratory diseases will follow adoption of improved cookstoves.
Background Drug and substance abuse has adverse health effects and a substantial economic burden ... more Background Drug and substance abuse has adverse health effects and a substantial economic burden to the global economies and at the household level. There is, however, limited data on socioeconomic disparities in the update of the substance of abuse in low-to-middle income countries such as Kenya. This study aimed to assess the socioeconomic disparities among drugs and substances in Murang'a county of central Kenya. Method The study design was cross-sectional, and data collection was conducted between November and December 2017. A total of 449 households with at least one person who has experienced substance abuse were sampled from four purposively selected sub-locations of Murang' a County. Household heads answered questions on house characteristics and as an abuser or on behalf of abusers in their households. Structured questionnaires were used to collect data on types of drugs used, economic burden, and gender roles at the household level. Household socioeconomic status (SES) was established (low, middle, and high SES) using principal component analysis (PCA) from a set of household assets and characteristics. Bivariable logistic regression analysis was used to assess the association between SES, gender, and other factors on the uptake of drugs and substance abuse. Results Individuals in higher SES were more likely to use cigarettes (OR = 2.13; 95%CI = 1.25-3.61, p = 0.005) or piped tobacco (OR = 11.37; 95% CI, 2.55-50.8; p-value = 0.001) than those in low SES. The wealthier individuals were less likely to use legal alcohol (OR = 0.39; 95%CI = 0.21-0.71, p = 0.002) than the poorest individuals. The use of prescription drugs did not vary with SES. A comparison of the median amount of money spent on acquiring drugs showed that richer individuals spent a significantly lower amount than the poorest individuals (USD 9.71 vs. Ksh 14.56, p = 0.031). Deaths related to drugs and substance abuse were more likely to occur in middle SES than amongst the poorest households (OR = 2.96; 95%CI = 1.03-8.45, p = 0.042). Conclusion Socioeconomic disparities exist in the use of drugs and substance abuse. Low-income individuals are at a higher risk of abuse, expenditures and even death. Strategies to reduce drugs and substance abuse must address socioeconomic disparities through targeted approaches to individuals in low-income groups.
Background: Drug and substance abuse has adverse health effects and a substantial economic burden... more Background: Drug and substance abuse has adverse health effects and a substantial economic burden to the global economies and at the household level. There is, however, limited data on socio-economic disparities in drugs and substance abuse in low-to-middle income countries such as Kenya. This study aimed to assess the socio-economic disparities in Murang’a county of central Kenya.Method: The study design was cross-sectional, and data collection was conducted between November and December 2017. A total of 449 households with at least one person who uses any drug or substance of abuse were randomly sampled from 4 purposively selected sub-locations of Murang’ a County. Structured questionnaires were used to collect data on types of drugs used, economic burden, and gender roles at the household level. Household socio-economic status (SES) was established (low, middle, and high SES ) using principal component analysis f(PCA) from a set of household assets and characteristics. Multivaria...
Background Malaria-endemic countries distribute long-lasting insecticidal nets (LLINs) through co... more Background Malaria-endemic countries distribute long-lasting insecticidal nets (LLINs) through combined channels with ambitious, universal coverage (UC) targets. Kenya has used eight channels with variable results. To inform national decision-makers, this two-arm study compares coverage (effects), costs, cost-effectiveness, and equity of two combinations of LLIN distribution channels in Kenya. Methods Two combinations of five delivery channels were compared as ‘intervention’ and ‘control’ arms. The intervention arm comprised four channels: community health volunteer (CHV), antenatal and child health clinics (ANCC), social marketing (SM) and commercial outlets (CO). The control arm consisted of the intervention arm channels except mass campaign (MC) replaced CHV. Primary analysis used random sample household survey data, service-provider costs, and voucher or LLIN distribution data to compare between-arm effects, costs, cost-effectiveness, and equity. Secondary analyses compared cost...
IntroductionAmid the rising number of people with non-communicable diseases (NCDs), Kenya has inv... more IntroductionAmid the rising number of people with non-communicable diseases (NCDs), Kenya has invested in strengthening primary care and in efforts to expand existing service delivery platforms to integrate NCD care. One such approach is the AMPATH (Academic Model Providing Access to Healthcare) model in western Kenya, which provides the platform for the Primary Health Integrated Care Project for Chronic Conditions (PIC4C), launched in 2018 to further strengthen primary care services for the prevention and control of hypertension, diabetes, breast and cervical cancer. This study seeks to understand how well PIC4C delivers on its intended aims and to inform and support scale up of the PIC4C model for integrated care for people with NCDs in Kenya.Methods and analysisThe study is guided by a conceptual framework on implementing, sustaining and spreading innovation in health service delivery. We use a multimethod design combining qualitative and quantitative approaches, involving: (1) i...
ABSTRACTBackgroundCase management of symptomatic COVID-19 patients is a key health system interve... more ABSTRACTBackgroundCase management of symptomatic COVID-19 patients is a key health system intervention. The Kenyan government embarked to fill capacity gaps in essential and advanced critical care needed for the management of severe and critical COVID-19. However, given scarce resources, gaps in both essential and advanced critical care persist. This study assessed the cost-effectiveness of investments in essential and advanced critical care to inform the prioritization of investment decisions.MethodsWe employed a decision tree model to assess the incremental cost-effectiveness of investment in essential care (EC) and investment in both essential and advanced critical care (EC+ACC) compared to current health care provision capacity (status quo) for COVID-19 patients in Kenya. We used a health system perspective, and an inpatient care episode time horizon. Cost data was obtained from primary empirical analysis while outcomes data was obtained from epidemiological model estimates. We ...
Policy makers in Africa need robust estimates of the current and future spread of SARS-CoV-2. Dat... more Policy makers in Africa need robust estimates of the current and future spread of SARS-CoV-2. Data suitable for this purpose are scant. We used national surveillance PCR test, serological survey and mobility data to develop and fit a county-specific transmission model for Kenya. We estimate that the SARS-CoV-2 pandemic peaked before the end of July 2020 in the major urban counties, with 34 41% of residents infected, and will peak elsewhere in the country within 2-3 months. Despite this penetration, reported severe cases and deaths are low. Our analysis suggests the COVID-19 disease burden in Kenya may be far less than initially feared. A similar scenario across sub-Saharan Africa would have implications for balancing the consequences of restrictions with those of COVID-19.
IntroductionCase management for COVID-19 patients is one of key interventions in country response... more IntroductionCase management for COVID-19 patients is one of key interventions in country responses to the pandemic. Countries need information on the costs of case management to inform resource mobilization, planning and budgeting, purchasing arrangements, and assessments of the cost-effectiveness of interventions. We estimated unit costs for COVID-19 case management for patients with asymptomatic, mild to moderate, severe, and critical COVID-19 disease in Kenya.MethodsWe estimated per patient per day unit costs of COVID-19 case management for patients that are asymptomatic and those that have mild to moderate, severe, and critical symptoms. For asymptomatic and mild to moderate patients, we estimated unit costs for home-based care and institutional (hospitals and isolation centers). We used an ingredients approach, adopted a health system perspective and patient episode of care as our time horizon. We obtained data on inputs and their quantities from COVID-19 case management guidel...
Supplemental material, Manuscript_Supplemental_Appendix.rjf_online_supp for The Costs of Implemen... more Supplemental material, Manuscript_Supplemental_Appendix.rjf_online_supp for The Costs of Implementing Vaccination With the RTS,S Malaria Vaccine in Five Sub-Saharan African Countries by Elisa Sicuri, Fadima Yaya Bocoum, Justice Nonvignon, Sergi Alonso, Bakar Fakih, George Bonsu, Simon Kariuki, Oscar Leeuwenkamp, Khatia Munguambe, Mwifadhi Mrisho, Vincent Were and Christophe Sauboin in MDM Policy & Practice
Dihydroartemisinin-piperaquine (DP) is a long-acting artemisinin combination treatment that provi... more Dihydroartemisinin-piperaquine (DP) is a long-acting artemisinin combination treatment that provides effective chemoprevention and has been proposed as an alternative antimalarial drug for intermittent preventive therapy in pregnancy (IPTp). Several pharmacokinetic studies have shown that dose adjustment may not be needed for the treatment of malaria in pregnancy with DP.
Background. The World Health Organization has recommended pilot implementation of a candidate vac... more Background. The World Health Organization has recommended pilot implementation of a candidate vaccine against malaria (RTS,S/AS01) in selected sub-Saharan African countries. This exploratory study aimed to estimate the costs of implementing RTS,S in Burkina Faso, Ghana, Kenya, Mozambique, and Tanzania. Methods. Key informants of the expanded program on immunization at all levels in each country were interviewed on the resources required for implementing RTS,S for routine vaccination. Unit prices were derived from the same sources or from international price lists. Incremental costs in 2015 US dollars were aggregated per fully vaccinated child (FVC). It was assumed the four vaccine doses were either all delivered at health facilities or the fourth dose was delivered in an outreach setting. Results. The costs per FVC ranged from US$25 (Burkina Faso) to US$37 (Kenya) assuming a vaccine price of US$5 per dose. Across countries, recurrent costs represented the largest share dominated by ...
Background To improve access to surgical care in rural Nicaragua, a collaboration was established... more Background To improve access to surgical care in rural Nicaragua, a collaboration was established between the Global Initiative for Children's Surgery (GICS), Operation Smile Nicaragua, and the Nicaragua Ministry of Health. Prior to implementation of the surgical programme Surgery for the People Nicaragua, our aim was to perform a baseline assessment of the Nicaraguan health system's capacity to provide safe surgical care in its rural zones. Methods In June and July 2017, a retrospective baseline evaluation of safe surgical care provision was performed at two rural district hospitals in Las Minas using the GICS Optimal Resources tool, the WHO/Program in Global Surgery & Social Change (PGSSC) Surgical Assessment tool, the World Federation of Societies of Anesthesiologists Assessment tool, and the PGSSC Qualitative Assessment tool. Main outcome measures were: surgical workforce density, surgical volume, perioperative mortality rates, level of infrastructure, access to essential medicines, and health system financing. Findings The surgical workforce density was six per 100 000 population, including one paediatric surgeon (the WHO target surgical workforce density is 20 per 100 000 population). The surgical volume was 1050 procedures per 100 000 population per year; less than 10% of the surgical volume was paediatric. Perioperative mortality rates were low but not routinely collected: range 0•12%-0•50%. There were major needs in infrastructure including: additional operating theatres; running water at one site; post-anaesthetic recovery room areas; and paediatric-specific surgical wards. There was adequate access to essential medications including oxygen, anaesthetics, and antibiotics. Care at the two district hospitals was free, and there were no recorded out-of-pocket expenses for surgical patients. Interpretation A major success of the Nicaraguan health system is free surgical care, protecting patients from catastrophic expenditure. However, to improve access to surgical care in rural Nicaragua, there is a need for investments in human resources, particularly in anaesthesia and paediatric providers. Furthermore, there is a need for monitoring and evaluation of key indicators including perioperative mortality and complication rates. Funding UBS Optimus Foundation.
Health inequality is a recognized barrier to achieving health-related development goals. Health-e... more Health inequality is a recognized barrier to achieving health-related development goals. Health-equality data are essential for evidence-based planning and assessing the effectiveness of initiatives to promote equity. Such data have been captured but have not always been analysed or used to manage programming. Health data were examined for microeconomic differences in malaria indices and associated malaria control initiatives in western Kenya. Data was analysed from a malaria cross-sectional survey conducted in July 2012 among 2719 people in 1063 households in Siaya County, Kenya. Demographic factors, history of fever, malaria parasitaemia, malaria medication usage, insecticide-treated net (ITN) use and expenditure on malaria medications were collected. A composite socioeconomic status score was created using multiple correspondence analyses (MCA) of household assets; households were classified into wealth quintiles and dichotomized into poorest (lowest 3 quintiles; 60%) or less-poo...
Most human Plasmodium infections in western Kenya are asymptomatic and are believed to contribute... more Most human Plasmodium infections in western Kenya are asymptomatic and are believed to contribute importantly to malaria transmission. Elimination of asymptomatic infections requires active treatment approaches, such as mass testing and treatment (MTaT) or mass drug administration (MDA), as infected persons do not seek care for their infection. Evaluations of community-based approaches that are designed to reduce malaria transmission require careful attention to study design to ensure that important effects can be measured accurately. This manuscript describes the study design and methodology of a cluster-randomized controlled trial to evaluate a MTaT approach for malaria transmission reduction in an area of high malaria transmission. Ten health facilities in western Kenya were purposively selected for inclusion. The communities within 3 km of each health facility were divided into three clusters of approximately equal population size. Two clusters around each health facility were r...
both overall and those considered specific to the antihypertensive drug. Perinatal outcomes studi... more both overall and those considered specific to the antihypertensive drug. Perinatal outcomes studied were fetal heart rate abnormalities, fetal and neonatal death, admission to the neonatal intensive care unit, and 5 minute Apgar score <7. Study quality was assessed and data were analyzed using a fixed effect model, with random effects modelling if heterogeneity was substantial. Seven randomized controlled trials involving 363 woman-infant pairs met the inclusion criteria. On primary analysis, oral nifedipine was associated with decreased risk of persistent hypertension (relative risk, 0.42; 95% confidence intervals, 0.18-0.96) and fewer maternal side effects (relative risk, 0.57; 95% confidence intervals, 0.35-0.94) compared with intravenous labetalol. However, following sensitivity analysis to explore the impact of study quality on effect size, the difference between drugs for persistent hypertension was no longer significant. No statistically significant differences were found for any of the other maternal or perinatal outcomes. The study concluded that oral nifedipine is as efficacious and safe as intravenous labetalol. Because of its ease of administration, it may have an edge in low resource settings. Although the authors recommend that larger studies be performed, they believe this meta-analysis is a useful comparative analysis of the safety and efficacy of oral nifedipine and intravenous labetalol for the treatment of severe hypertension in parturients.
Although anti-malarial medicines are free in Kenyan public health facilities, patients often seek... more Although anti-malarial medicines are free in Kenyan public health facilities, patients often seek treatment from private sector retail drug outlets. In mid-2010, the Affordable Medicines Facility-malaria (AMFm) was introduced to make quality-assured artemisinin-based combination therapy (ACT) accessible and affordable in private and public sectors. Private sector retail drug outlets stocking anti-malarial medications within a surveillance area of approximately 220,000 people in a malaria perennial high-transmission area in rural western Kenya were identified via a census in September 2013. A cross-sectional study was conducted in September-October 2013 to determine availability and price of anti-malarial medicines and malaria rapid diagnostic tests (RDTs) in drug outlets. A standardized questionnaire was administered to collect drug outlet and personnel characteristics and availability and price of anti-malarials and RDTs. Of 181 drug outlets identified, 179 (99 %) participated in t...
In 2007, the US Centers for Disease Control and Prevention partnered with local Kenyan institutio... more In 2007, the US Centers for Disease Control and Prevention partnered with local Kenyan institutions to implement the Nyando Integrated Child Health and Education Project, an effectiveness study that used social marketing and a community-based distribution program to promote the sale of Sprinkles and other health products. To describe monitoring of wholesale sales, household demand, promotional strategies, and perceived factors influencing Sprinkles sales among vendors. Ongoing quantitative and qualitative monitoring of Sprinkles sales began in May 2007 in 30 intervention villages. Data sources included baseline and follow-up cross-sectional surveys; office records of Sprinkles sales to vendors; biweekly household monitoring of Sprinkles use; and qualitative data collection, including vendor focus groups and key informant interviews. A total of 550 children aged 6 to 35 months were enrolled at baseline, and 451 were available at 12-month follow-up. During this period, nearly 160,000 ...
Monitoring local malaria transmission intensity is essential for planning evidence-based control ... more Monitoring local malaria transmission intensity is essential for planning evidence-based control strategies and evaluating their impact over time. Anti-malarial antibodies provide information on cumulative exposure and have proven useful, in areas where transmission has dropped to low sustained levels, for retrospectively reconstructing the timing and magnitude of transmission reduction. It is unclear whether serological markers are also informative in high transmission settings, where interventions may reduce transmission, but to a level where considerable exposure continues. This study was conducted through ongoing KEMRI and CDC collaboration. Asembo, in Western Kenya, is an area where intense malaria transmission was drastically reduced during a 1997-1999 community-randomized, controlled insecticide-treated net (ITN) trial. Two approaches were taken to reconstruct malaria transmission history during the period from 1994 to 2009. First, point measurements were calculated for serop...
Background: Exposure to household air pollutants released during cooking has been linked to numer... more Background: Exposure to household air pollutants released during cooking has been linked to numerous adverse health outcomes among residents of rural areas in low-income countries. Improved cookstoves are one of few available interventions, but achieving equity in cookstove access has been challenging. Therefore, innovative approaches are needed. To evaluate a project designed to motivate adoption of locally-produced, ceramic cookstoves (upesi jiko) in an impoverished, rural African population, we assessed the perceived benefits of the cookstoves (in monetary and time-savings terms), the rate of cookstove adoption, and the equity of adoption. Methods: The project was conducted in 60 rural Kenyan villages in 2008 and 2009. Baseline (n = 1250) and follow-up (n = 293) surveys and a stove-tracking database were analyzed. Results: At baseline, nearly all respondents used wood (95%) and firepits (99%) for cooking; 98% desired smoke reductions. Households with upesi jiko subsequently spent <100 Kenyan Shillings/week on firewood more often (40%) than households without upesi jiko (20%) (p = 0.0002). There were no significant differences in the presence of children <2 years of age in households using upesi jiko (48%) or three-stone stoves (49%) (p = 0.88); children 2-5 years of age were less common in households using upesi jiko versus three-stone stoves (46% and 69%, respectively) (p = 0.0001). Vendors installed 1,124 upesi jiko in 757 multi-family households in 18 months; 68% of these transactions involved incentives for vendors and purchasers. Relatively few (<10%) upesi jiko were installed in households of women in the youngest age quartile (<22 years) or among households in the poorest quintile. Conclusions: Our strategy of training of local vendors, appropriate incentives, and product integration effectively accelerated cookstove adoption into a large number of households. The strategy also created opportunities to reinforce health messages and promote cookstoves sales and installation. However, the project's overall success was diminished by inequitable and incomplete adoption by households with the lowest socioeconomic status and young children present. Additional evaluations of similar strategies will be needed to determine whether our strategy can be applied equitably elsewhere, and whether reductions in fuel use, household air pollution, and the incidence of respiratory diseases will follow adoption of improved cookstoves.
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