Cost structure of healthcare in Kaloleni Subcounty (Kilifi, Kenya) from the patient perspective: Measuring the impact of direct healthcare costs on patients

Access to quality, affordable, and reliable healthcare has been a long-standing challenge in rural areas of developing countries. Rural households often incur high out-of-pocket expenditure for healthcare, resulting in a significant cost burden when seeking treatment for an illness. This study aimed to examine the cost structure of healthcare in a rural, underserved community in the Kaloleni Subcounty of Kilifi, Kenya. We measured the impact of direct healthcare costs on a sample of 37 households, along with the coping strategies and treatment-seeking behavior arising from these costs. Direct healthcare costs were grouped into 3 categories: consultation, diagnostic, and medicine fees. Results show that medicine was the highest direct healthcare cost, accounting for 64% of all expenses paid during an episode of illness. Direct healthcare costs also comprised over 12% of the monthly household expenditure in these households, with the lowest-earning homes being disproportionately affected. Malaria was the most common illness reported in the study area, accounting for 37% of all illness cases. Several strategies are proposed to ease the burden of direct healthcare costs. These include government subsidies for community-level healthcare facilities, increasing the availability of medicines, and improving the distribution/use of treated mosquito bed nets to prevent malaria transmission.

Experiences of women seeking care for abortion complications in health facilities: Secondary analysis of the WHO Multi-Country Survey on Abortion in 11 African countries

Objective
Despite evidence of acute and long-term consequences of suboptimal experiences of care, standardized measurements across countries remain limited, particularly for postabortion care. We aimed to determine the proportion of women reporting negative experiences of care for abortion complications, identify risk factors, and assess the potential association with complication severity.

Methods
Data were sourced from the WHO Multi-Country Survey on Abortion for women who received facility-based care for abortion complications in 11 African countries. We measured women’s experiences of care with eight questions from an audio computer-assisted self-interview related to respect, communication, and support. Multivariable generalized estimating equations were used for analysis.

Results
There were 2918 women in the study sample and 1821 (62%) reported at least one negative experience of postabortion care. Participants who were aged under 30 years, single, of low socioeconomic status, and economically dependent had higher odds of negative experiences. Living in West or Central Africa, rather than East Africa, was also associated with reportedly worse care. The influence of complication severity on experience of care appeared significant, such that women with moderate and severe complications had 12% and 40% higher odds of reporting negative experiences, respectively.

Conclusion
There were widespread reports of negative experiences of care among women receiving treatment for abortion complications in health facilities. Our findings contribute to the scant understanding of the risk factors for negative experiences of postabortion care and highlight the need to address harmful provider biases and behaviors, alleviate health system constraints, and empower women in demanding better care.

Professional identity transitions, violations and reconciliations among new nurses in low- and middle-income countries

We examine how new nurses construct their professional identity in Low- and Middle-Income Countries (LMICs) when they enter clinical practice and encounter practical norms violating procedural standards. We conducted interviews and focus group discussions with 47 Kenyan nurses. We describe new nurses experiencing ‘shock’ entering nursing practice (working and learning alone while responsible for many patients and doing ‘dirty work’), which contrasted with their idealized image and expectations of nursing and prior training. We explain this transition using theory about identity and identity work, which we argue elucidates nurses’ experiences in LMICs. We suggest that nurses’ transition into clinical practice violated pre-existing expectations for their professional identities, which then triggered identity work of ‘toughening up’, ‘maturing through experience’, and ‘learning practical norms’. Through this identity work, and finally experiencing satisfaction from caring for and nursing patients back to health, some nurses were able to restore their valued professional identity.

Our findings highlight the need for professional educators and healthcare policymakers in LMICs to reconsider the way new healthcare workers are prepared for and socialized into professional practice, acknowledging that nursing practice is often very different to training. We argue for developing formative spaces in which health professionals can safely discuss practical norms deviating from procedural standards. Drawing on such conversations, practical norms benefitting the quality and safety in resource constrained contexts might then be incorporated into care standards and ways found to address practical norms harming of patient care.

A Cybersecurity Model for the Health Sector: A Case Study of Hospitals in Nairobi, Kenya

Internet crime is perceived to be an advanced type of crime that has not yet infiltrated third world countries like Kenya. Cybercrime is growing in all parts of the world, and most users of the internet have fallen victims at one point in time. Most victims suffer and do not speak out especially healthcare institutions due to the fear of backlash from the general public. Moreover, the cybercrimes threats to healthcare equipment, electronic healthcare technology is prevalent worldwide and creates enormous potential to improve clinical outcomes and transform the delivery of care. Overall, this study strived to come up with a cyber-security framework for fighting cybercrime in the health sector in Kenya. Specifically, this research project sought to outline the major cyber threats and vulnerabilities, develop a cyber-security framework and validate it for adoption within health sector in Kenya. A descriptive research design was adopted in the study. The population of the study consisted of Mediheal group of hospitals staff. The study focused on top and mid-level IT and other departmental heads that work for Mediheal group of hospitals in Nairobi Kenya. The hospital had a total of 206 staff in Nairobi. This study used convenience sampling. Based on the Yamane formula, the study sampled 135 employees from all departments of Mediheal group of hospitals. Primary data was gathered by use of a questionnaire. Frequency tables and percentages were used to present the findings. Correlation and simple regression analysis were used to indicate simple relationships between individual constructs with the dependent variable. For model evaluation, Structural Equation Modelling (SEM) was used. The study found that top management commitment had a moderate influence on cybersecurity (r = .338, p = .000), organizational factors had a strong influence on cybersecurity (r = .604, p = .000), IT policies had a weak influence on cybersecurity (r = .209, p = .028), and IT literacy had a strong influence on cybersecurity (r = .642, p = .000). From SEM analysis, the study confirmed that the path coefficients were positive for top management commitment, organizational factors and IT literacy with cybersecurity. The paths coefficients were, however, negative for IT policies and threats and vulnerabilities with cybersecurity. The study recommends that monitoring of the performance of cybersecurity as well as continuous awareness and training programs on cyber security for all employees are needed.

Gastrointestinal endoscopy capacity in Eastern Africa

Background and study aims Limited evidence suggests that endoscopy capacity in sub-Saharan Africa is insufficient to meet the levels of gastrointestinal disease. We aimed to quantify the human and material resources for endoscopy services in eastern African countries, and to identify barriers to expanding endoscopy capacity.

Patients and methods In partnership with national professional societies, digestive healthcare professionals in participating countries were invited to complete an online survey between August 2018 and August 2020.

Results Of 344 digestive healthcare professionals in Ethiopia, Kenya, Malawi, and Zambia, 87 (25.3 %) completed the survey, reporting data for 91 healthcare facilities and identifying 20 additional facilities. Most respondents (73.6 %) perform endoscopy and 59.8 % perform at least one therapeutic modality. Facilities have a median of two functioning gastroscopes and one functioning colonoscope each. Overall endoscopy capacity, adjusted for non-response and additional facilities, includes 0.12 endoscopists, 0.12 gastroscopes, and 0.09 colonoscopes per 100,000 population in the participating countries. Adjusted maximum upper gastrointestinal and lower gastrointestinal endoscopic capacity were 106 and 45 procedures per 100,000 persons per year, respectively. These values are 1 % to 10 % of those reported from resource-rich countries. Most respondents identified a lack of endoscopic equipment, lack of trained endoscopists and costs as barriers to provision of endoscopy services.

Conclusions Endoscopy capacity is severely limited in eastern sub-Saharan Africa, despite a high burden of gastrointestinal disease. Expanding capacity requires investment in additional human and material resources, and technological innovations that improve the cost and sustainability of endoscopic services.

Aetiology and outcomes of operatively managed acute abdomen in adults, at Moi Teaching and Referral Hospital

Background: Acute abdomen is responsible for up to 50% of surgical emergencies. Its aetiological patterns are thought to be changing in Africa. Despite its frequent occurrence, the aetiology and outcomes of operatively managed acute abdomen, in adults, is yet to be described at Moi Teaching and Referral Hospital (MTRH). This description of will be informative to clinical practitioners and improve care of patients Objective: To determine the aetiology and outcomes of operatively managed acute abdominal conditions, in adults at Moi Teaching and Referral Hospital MTRH. Methods: A prospective descriptive study was carried out in the general surgical and gynaecology wards. Fischer‟s statistical formula was used to determine sample size, and consecutive sampling was done until the sample size was achieved. A sample of 203 adult patients, 18 years and older, operated on for an acute abdomen between 29th March 2018 to 29th March 2019, were studied. Patients with abdominal trauma causing acute abdomen were excluded. A data sheet was used to record the aetiology and outcomes (early complications, mortality and duration of stay). Descriptive statistical analysis such as frequencies and percentages were used for categorical variables. Measures of central tendency such as mean and interquartile ranges were used for continuous variables. Univariate analysis was used to assess association between the outcome and the aetiology. Results: 203 patients with a median age of 29 years (IQR 23, 35.5) were studied. One hundred and twenty-one (59.6%) were female and eighty-two (40.4%) were male. The most common causes of operative acute abdomen included: ectopic pregnancy 72(35.5%), intestinal obstruction 46(22.7%) and appendicitis 37(18. 7%). Three (1.5%) patients died. Postoperative complication rate was 20.7%. Wound dehiscence (8.4%), surgical site infection (7.9%), pneumonia (3.4%), then sepsis (2.5%) were the most encountered complications. A majority of patients 124(63.5%) were discharged within a week of admission. Aetiology was found to be associated with likelihood of developing wound dehiscence (p 0.003) and surgical site infection (p 0.004) postoperatively. Conclusion: Ectopic pregnancy is the most frequently encountered cause of operative acute abdomen at MTRH. It is followed by intestinal obstruction, appendicitis, then bowel perforations in that order. Wound complications, pneumonia then sepsis are the commonly encountered complications. Recommendation: A 5-10 yearly review of acute abdominal aetiology should be carried out at MTRH to allow us to monitor for any future changes. Studies should be carried out on perioperative factors affecting wound dehiscence with the aim of reducing its occurrence.

Effect of the Procurement Function on the Utilisation of Medical Devices in Public Level Five Hospitals in Kenya

The purpose of the study was to investigate effect of procurement function on the utilization of medical devices in level five hospital in Kenya. More specifically, the study set to answer three key questions namely: What is the effect of procurement practices on utilization of medical devices in public Level Five Hospitals in Kenya? What is the effect of Human capital considerations during procurement on Utilization of Medical Devices? How has maintenance and technical support considerations during procurement affected utilization of medical devices in public Level Five Hospitals in Kenya? With respect to methodological approach, the study was guided by descriptive research design, with a focus on 12 public Level Five Hospitals in Kenya and a study sample size of 138 respondents who were staffs. Stratified sampling techniques was used in selecting respondents, and data collected using self-administered questionnaires, and subsequently analyzed using Statistical Package for Social Sciences (SPSS) version 25. The findings revealed that there were glaring inadequacies in roped to maintenance and technical support of medical devices, human capital considerations during procurement and procurement practices that should otherwise enhance the utilization of medical devices. The findings on procurement practices revealed that there no collaboration while making procurement decisions and this would have resulted to poor utilization of medical devices. The findings further indicate that there was a gap in human capacity and skills and this hindered effective utilization of medical devices. On maintenance and technical support, the findings revealed procured medical devices were not properly maintained due to factors like inadequate skilled workforce responsible for maintenance of medical devices. The results revealed that the relationship between medical device utilization and procurement practices. r (98) =.179, p=.03, maintenance and technical support, r (98) =239, p=.045, and human capital considerations were fairly weak, r (98) =.231, p=.015. The study concludes that there exists fundamental gaps and practices within the procurement function in general that is aiding the effective utilization of medical devices in level five hospitals. The study recommends that human capacity and skills improvement that relate to the users of medical equipment should be a continuous operational function whose cost should be part and parcel of the procurement process as a whole. Secondly, medical equipment maintenance and technical support should be considered as a strategic procurement imperative when any buying decision processes are been done. Lastly, there is need to examine, or to evaluate whether public healthcare services would be more effective as a devolved function or managed by the national government, just like education. The study further concludes there is need for all the departments to work together to have optimal utilization of medical devices that is the procurement division work together with the human resource and the maintenance department to ensure the require medical devices are procured, staff are well trained and there is proper maintenance and if this is properly collaborated there will be optimal utilization of medical devices.

Understanding patient health-seeking behaviour to optimise the uptake of cataract surgery in rural Kenya, Zambia and Uganda: findings from a multisite qualitative study

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.

Functional assessment of long bone fracture healing in Samburu County Referral Hospital (Kenya): the squat and smile challenge

Background:
The burden of musculoskeletal trauma is increasing in low- and middle-income countries. Due to the low clinical follow-up rates in these regions, the Squat-and-Smile test (S&S) has previously been proposed as a proxy to assess bone healing (BH) capacity after surgery involving bone fractures. This study deals with various aspects of using S&S and bone radiography examination to obtain information about an individual’s ability to recover after a trauma. In summary, we performed the S&S test to assess the possibility of recovering biomechanical function in lower limbs in a remote area of Kenya (Samburu County).

Methods:
Eighty-nine patients (17.9% F; 31.7 ± 18.9 yrs) who underwent intramedullary nail treatment for femur or tibia fractures were enrolled in this study. Both S&S [evaluated by a goal attainment scale (GAS)] and x-ray (evaluated by REBORNE, Bone Healing Score) were performed at 6 and 24 weeks, postoperatively. An acceptable margin for satisfactory S&S GAS scores was determined by assessing its validity, reliability, and sensitivity.

Results:
S&S GAS scores increased over time: 80.2% of patients performed a satisfactory S&S at the 24-weeks follow-up with a complete BH. A high correlation between S&S GAS and REBORNE at the 6- and 24- weeks’ timepoint was found. Facial expression correlated partially with BH. The S&S proved to be accurate at correctly depicting the BH process (75% area fell under the Receiver Operator Curve).

Conclusion:
The S&S provides a possible substitution for bone x-ray during BH assessment. The potential to remotely follow up the BH is certainly appealing in low- and middle-income countries, but also in high-income countries; as was recently observed with the Covid-19 pandemic when access to a hospital is not conceivable.

Task-sharing to support paediatric and child health service delivery in low- and middle-income countries: current practice and a scoping review of emerging opportunities

Background
Demographic and epidemiological changes have prompted thinking on the need to broaden the child health agenda to include care for complex and chronic conditions in the 0–19 years (paediatric) age range. Providing such services will be undermined by general and skilled paediatric workforce shortages especially in low- and middle-income countries (LMICs). In this paper, we aim to understand existing, sanctioned forms of task-sharing to support the delivery of care for more complex and chronic paediatric and child health conditions in LMICs and emerging opportunities for task-sharing. We specifically focus on conditions other than acute infectious diseases and malnutrition that are historically shifted.

Methods
We (1) reviewed the Global Burden of Diseases study to understand which conditions may need to be prioritized; (2) investigated training opportunities and national policies related to task-sharing (current practice) in five purposefully selected African countries (Kenya, Uganda, Tanzania, Malawi and South Africa); and (3) summarized reported experience of task-sharing and paediatric and child health service delivery through a scoping review of research literature in LMICs published between 1990 and 2019 using MEDLINE, Embase, Global Health, PsycINFO, CINAHL and the Cochrane Library.

Results
We found that while some training opportunities nominally support emerging roles for non-physician clinicians and nurses, formal scopes of practices often remain rather restricted and neither training nor policy seems well aligned with probable needs from high-burden complex and chronic conditions. From 83 studies in 24 LMICs, and aside from the historically shifted conditions, we found some evidence examining task-sharing for a small set of specific conditions (circumcision, some complex surgery, rheumatic heart diseases, epilepsy, mental health).

Conclusion
As child health strategies are further redesigned to address the previously unmet needs careful strategic thinking on the development of an appropriate paediatric workforce is needed. To achieve coverage at scale countries may need to transform their paediatric workforce including possible new roles for non-physician cadres to support safe, accessible and high-quality care.