Assessing the impact of a primary care electronic medical record system in three Kenyan rural health centers

Objective: Efficient, effective health care requires rapid availability of patient information. We designed, implemented, and assessed the impact of a primary care electronic medical record (EMR) in three rural Kenyan health centers. Method: Local clinicians identified data required for primary care and public health reporting. We designed paper encounter forms to capture these data in adult medicine, pediatric, and antenatal clinics. Encounter form data were hand-entered into a new primary care module in an existing EMR serving onsite clinics serving patients infected with the human immunodeficiency virus (HIV). Before subsequent visits, Summary Reports were printed containing selected patient data with reminders for needed HIV care. We assessed effects on patient flow and provider work with time-motion studies before implementation and two years later, and we surveyed providers' satisfaction with the EMR. Results: Between September 2008 and December 2011, 72 635 primary care patients were registered and 114 480 encounter forms were completed. During 2011, 32 193 unique patients visited primary care clinics, and encounter forms were completed for all visits. Of 1031 (3.2%) who were HIV-infected, 85% received HIV care. Patient clinic time increased from 37 to 81 min/visit after EMR implementation in one health center and 56 to 106 min/visit in the other. However, outpatient visits to both health centers increased by 85%. Three-quarters of increased time was spent waiting. Despite nearly doubling visits, there was no change in clinical officers' work patterns, but the nurses' and the clerks' patient care time decreased after EMR implementation. Providers were generally satisfied with the EMR but desired additional training. Conclusions: We successfully implemented a primary care EMR in three rural Kenyan health centers. Patient waiting time was dramatically lengthened while the nurses' and the clerks' patient care time decreased. Long-term use of EMRs in such settings will require changes in culture and workflow

A computer-based medical record system and personal digital assistants to assess and follow patients with respiratory tract infections visiting a rural Kenyan health centre

BACKGROUND: Clinical research can be facilitated by the use of informatics tools. We used an existing electronic medical record (EMR) system and personal data assistants (PDAs) to assess the characteristics and outcomes of patients with acute respiratory illnesses (ARIs) visiting a Kenyan rural health center. METHODS: We modified the existing EMR to include details on patients with ARIs. The EMR database was then used to identify patients with ARIs who were prospectively followed up by a research assistant who rode a bicycle to patients' homes and entered data into a PDA. RESULTS: A total of 2986 clinic visits for 2009 adult patients with respiratory infections were registered in the database between August 2002 and January 2005; 433 patients were selected for outcome assessments. These patients were followed up in the villages and assessed at 7 and 30 days later. Complete follow-up data were obtained on 381 patients (88%) and merged with data from the enrollment visit's electronic medical records and subsequent health center visits to assess duration of illness and complications. Symptoms improved at 7 and 30 days, but a substantial minority of patients had persistent symptoms. Eleven percent of patients sought additional care for their respiratory infection. CONCLUSION: EMRs and PDA are useful tools for performing prospective clinical research in resource constrained developing countries

Public Service Delivery: Role of Information and Communication Technology in Improving Governance and Development Impact

The focus of this paper is on improving governance through the use of information and communication technology (ICT) in the delivery of services to the poor, i.e., improving efficiency, accountability, and transparency, and reducing bribery. A number of papers recognize the potential benefits but they also point out that it has not been easy to harness this potential. This paper presents an analysis of effective case studies from developing countries where the benefits have reached a large number of poor citizens. It also identifies the critical success factors for wide-scale deployment. The paper includes cases on the use of ICTs in the management of delivery of public services in health, education, and provision of subsidized food. Cases on electronic delivery of government services, such as providing certificates and licenses to rural populations, which in turn provide entitlements to the poor for subsidized food, fertilizer, and health services are also included. ICT-enabled provision of information to enhance rural income is also covered

Assessing service availability before and after the introduction of free maternity services at the Pumwani maternity Hospital

Maternal health is the state of health of women during pregnancy, childbirth and the postpartum period. The Kenyan government introduced free maternal healthcare services in June 2013 to address the high maternal mortality rates that stood at 362 per 100000 live births in 2016. Maternal Mortality rate in Nairobi County was estimated to be at 57.1 per 100000 live births as of 2014. The study aimed at contributing towards strengthening maternity services by assessing the availability of maternity services before and after the introduction of the free maternity services policy at the Pumwani Maternity Hospital. This was a mixed method study; quantitative study (data from existing records) employing longitudinal study design and qualitative study where in depth interviews were conducted on six respondents using topic guides. This was simple and allowed evaluation of variables that change before and after interventions. The study was conducted in the month of February 2018 and was for the periods 2009 to 2017. The implementation of the free maternity services resulted to a 1974.75 mean increase in admissions, 1840.42 mean increase in total deliveries of which 1358.50 was increase in normal deliveries and 478.50 caesarian deliveries. These figures as seen in the analysis had not been recorded in the facility before and it is important also to note that these figures decline through the years. There was no much variation in the infrastructure, equipment and personnel and coping mechanisms largely relied on the Pumwani Maternity team. Similar studies are required both in the facility and the private entities to come up with recommendations on how to keep the numbers high and sustain the free maternity services policy. This study therefore contributes to knowledge that would inform policy in Kenya and other countries that seek to subsidize maternity services

Opportunities and challenges for implementing cost accounting systems in the Kenyan health system.

Low- and middle-income countries need to sustain efficiency and equity in health financing on their way to universal health care coverage. However, systems meant to generate quality economic information are often deficient in such settings. We assessed the feasibility of streamlining cost accounting systems within the Kenyan health sector to illustrate the pragmatic challenges and opportunities. We reviewed policy documents, and conducted field observations and semi-structured interviews with key informants in the health sector. We used an adapted Human, Organization and Technology fit (HOT-fit) framework to analyze the components and standards of a cost accounting system. Among the opportunities for a viable cost accounting system, we identified a supportive broad policy environment, political will, presence of a national data reporting architecture, good implementation experience with electronic medical records systems, and the availability of patient clinical and resource use data. However, several practical issues need to be considered in the design of the system, including the lack of a framework to guide the costing process, the lack of long-term investment, the lack of appropriate incentives for ground-level staff, and a risk of overburdening the current health management information system. To facilitate the implementation of cost accounting into the health sector, the design of any proposed system needs to remain simple and attuned to the local context

Centers for Disease Control and Prevention Kenya annual report 2016

Our Mission: To protect and improve health in Kenya and globally through science, communication, policy, partnership, and evidence- based public health action.For 40 years, the Centers for Disease Control and Prevention (CDC) has helped strengthen public health and laboratory systems in Kenya, creating an integrated research and program center. This model ties together multiple program areas, leveraging technical skills and a strong partnership with the Government of Kenya to build sustainable public health capacity. CDC Kenya saves lives by conducting research on the effectiveness of new interventions and by preventing disease, reducing death and disability, and implementing evidence-based public health programs.CS 305704-ACDC in Kenya \ua0-- Four Decades Forward: CDC Kenya Celebrates 40th Anniversary \ua0-- Timeline of Key Events \ua0-- Acronyms \ua0-- Science \ua0-- Service \ua0-- Surveillance \ua0-- International Accolades \ua0-- Publications.2019722

Shamba Maisha: Pilot Agricultural Intervention For Food Security And HIV Health Outcomes In Kenya: Design, Methods, Baseline Results And Process Evaluation Of A Cluster-Randomized Controlled Trial

Background: Despite advances in treatment of people living with HIV, morbidity and mortality remains unacceptably high in sub-Saharan Africa, largely due to parallel epidemics of poverty and food insecurity.Methods/Design: We conducted a pilot cluster randomized controlled trial (RCT) of a multisectoral agricultural and microfinance intervention (entitled Shamba Maisha) designed to improve food security, household wealth, HIV clinical outcomes and women’s empowerment. The intervention was carried out at two HIV clinics in Kenya, one randomizedto the intervention arm and one to the control arm. HIV-infected patients >18 years, on antiretroviral therapy, with moderate/severe food insecurity and/or body mass index (BMI) <18.5, and access to land and surface water were eligible for enrollment. The intervention included: 1) a microfinance loan (~$150) to purchase the farming commodities,2) a micro-irrigation pump, seeds, and fertilizer, and 3) trainings in sustainable agricultural practices and financial literacy. Enrollment of 140 participants took four months, and the screening-to-enrollment ratio was similar between arms. We followed participants for 12 months and conducted structured questionnaires. We also conducted a process evaluation with participants and stakeholders 3–5 months after study start and at study end.Discussion: Baseline results revealed that participants at the two sites were similar in age, gender and maritalstatus. A greater proportion of participants at the intervention site had a low BMI in comparison to participants at the control site (18% vs. 7%, p = 0.054). While median CD4 count was similar between arms, a greater proportionof participants enrolled at the intervention arm had a detectable HIV viral load compared with control participants (49% vs. 28%, respectively, p < 0.010). Process evaluation findings suggested that Shamba Maisha had high acceptability in recruitment, delivered strong agricultural and financial training, and led to labor saving due to use of the water pump.Implementation challenges included participant concerns about repaying loans, agricultural challenges due to weather patterns, and a challenging partnership with the microfinance institution. We expect the results from this pilotstudy to provide useful data on the impacts of livelihood interventions and will help in the design of a definitive cluster RCT

Improving the Reach and Effectiveness of Palliative Care in Low-Resource Countries

Purpose: The purpose of this compendium is to identify strategies to extend the reach and effectiveness of palliative care in low resource countries by 1) examining palliative care interventions, outcomes, and outcome measures, 2) evaluating a home-based palliative care program in rural India, and 3) exploring the concept of acceptability of rural medical practitioners in rural India. Problem: Limited access to effective palliative care services remains an urgent global concern for the over 19 million people requiring palliative care, the majority of whom live in low resource countries. An accompanying lack of research into palliative care interventions in resource-poor areas to support the development of feasible, acceptable, and useful context-specific interventions also exists. This dissertation is a compendium of three manuscripts that represent studies designed to offer information about improving the reach and effectiveness of palliative care in low resource countries. Design: The research designs used to carry out these studies included a systematic review of the literature that identified palliative care interventions and patient outcomes in low resource countries and the outcome measures used to evaluate the interventions (manuscript 1); the qualitative evaluation using a grounded theory approach of a pilot palliative care program in a rural area outside Kolkata, India, from the perspective of key stakeholder (manuscript 2) using a grounded theory approach, and dimensional concept analysis of the acceptance of rural medical practitioners (RMPs) as health care providers in rural India (manuscript 3). Findings: Findings from the systematic review characterize the types of palliative care models available in low resource areas while highlighting the need for more rigorous research to help guide the development of effective palliative care programs. It also reports the need for validation of palliative care outcome measures that are designed for and validated in low resource settings. Findings from the qualitative evaluation of the palliative care program indicated the value of the program for stakeholders in terms of the delivery of palliative care to rural cancer patients. The palliative care program incorporating the training of RMPs as CHWs is a model worthy of consideration by other low resource areas of India. The results of the dimensional concept analysis revealed five dimensions and two sub-dimensions for acceptability: accessibility with two subdimensions of availability and proximity; affordable, familiar, satisfactory, and trusted. The findings suggest that using RMPs in health care interventions in rural India may be feasible because of their acceptability across stakeholders. Conclusion: The reach and effectiveness of palliative care in low resource countries may be expanded by additional rigorous research on palliative care interventions to support the development of context-specific programs. The evaluation of home-based palliative care programs from the perspective of key stakeholders will help identify strengths of the program and opportunities for improvement. The concept of acceptability may be used to design interventions that employ RMPs to deliver health care in rural areas of India

Evaluating the impact of the DREAMS partnership to reduce HIV incidence among adolescent girls and young women in four settings: a study protocol

Abstract Background: HIV risk remains unacceptably high among adolescent girls and young women (AGYW) in southern and eastern Africa, reflecting structural and social inequities that drive new infections. In 2015, PEPFAR (the United States President’s Emergency Plan for AIDS Relief) with private-sector partners launched the DREAMS Partnership, an ambitious package of interventions in 10 sub-Saharan African countries. DREAMS aims to reduce HIV incidence by 40% among AGYW over two years by addressing multiple causes of AGYW vulnerability. This protocol outlines an impact evaluation of DREAMS in four settings. Methods: To achieve an impact evaluation that is credible and timely, we describe a mix of methods that build on longitudinal data available in existing surveillance sites prior to DREAMS roll-out. In three long-running surveillance sites (in rural and urban Kenya and rural South Africa), the evaluation will measure: (1) population-level changes over time in HIV incidence and socio-economic, behavioural and health outcomes among AGYW and young men (before, during, after DREAMS); and (2) causal pathways linking uptake of DREAMS interventions to ‘mediators’ of change such as empowerment, through to behavioural and health outcomes, using nested cohort studies with samples of ~ 1000–1500 AGYW selected randomly from the general population and followed for two years. In Zimbabwe, where DREAMS includes an offer of pre-exposure HIV prophylaxis (PrEP), cohorts of young women who sell sex will be followed for two years to measure the impact of ‘DREAMS+PrEP’ on HIV incidence among young women at highest risk of HIV. In all four settings, process evaluation and qualitative studies will monitor the delivery and context of DREAMS implementation. The primary evaluation outcome is HIV incidence, and secondary outcomes include indicators of sexual behavior change, and social and biological protection. Discussion: DREAMS is, to date, the most ambitious effort to scale-up combinations or ‘packages’ of multi-sectoral interventions for HIV prevention. Evidence of its effectiveness in reducing HIV incidence among AGYW, and demonstrating which aspects of the lives of AGYW were changed, will offer valuable lessons for replication. Keywords: HIV prevention, Adolescent health, Complex intervention, Impact evaluation, Gender equity, Kenya, South Africa, Zimbabw

Factors Affecting the Quality of Services Provided to Female Survivors of Sexual Violence in Nairobi, Kenya: Perspectives from Health Practitioners

This study examined the experiences of practitioners facing the challenges of providing services to female survivors of sexual violence in Kenya. Specifically, the study examined how health practitioners understand their experience in responding to the needs of sexual violence survivors, how they view these women, in what ways they are helping them to heal, and in what ways the health system fails to help these women. In-depth interviews were conducted with 28 health practitioners, from eight post-rape care facilities located in Nairobi, Kenya. The questions focused on the practitioners’ workload, challenges and rewards, the emotional impact of working with survivors, and recommendations for improving the quality of services that they provide. The study documented a myriad of detail about the working conditions of the practitioners, the problems they face, and the quality of services they provide. The results revealed three findings that were particularly salient and significant. The most striking result is the severe shortages of personnel, equipment and competency in delivering services to survivors. Second, the study uncovered complex and troubling issues concerning the question of genuine clients. In recounting their experiences, the practitioners described cases where it became apparent that the women presenting in the clinic had not actually been raped, but used the pretext to obtain HIV pre-exposure prophylaxis medication. Thus, doubts about the veracity of the client’s story added to the emotional drain on the providers. The third significant finding was the great pressure exerted on survivors not to report or to follow-up on cases when the perpetrator was a family member. The experience was less often voiced as feelings of shame about the act of incest, but more often expressed as the fear of financial ruin for the family if the male primary income earner were sent to jail. An explanation for the occurrence of these disparate results points to common origins in social structural inequities driven by the global political economic policies that perpetuate poverty and dependency throughout Africa and the developing world. The results of this study have many important implications for improving the quality of services provided to rape survivors in Kenya