Pragmatic pluralism for health: Understanding the role of public financing and public-private engagement on use, quality, and equity in access to maternal health services in Kenya

This thesis assesses the effects of having pluralistic systems of health financing and service provision on universal healthcare coverage with a case study on maternal health in Kenya. Through five research papers using a mix of systematic literature review, qualitative, and quasi-experimental quantitative methods, this thesis answers three primary research questions. First, how do researchers measure the contribution of the private sector to maternal health and family planning service provision and how much care does the private sector provide in sub-Saharan Africa (SSA)? Second, how did Kenya’s pluralistic financing policies and public-private engagement strategies for health arise and evolve over time? Finally, what are the impacts of user fee removals and subsidized vouchers on use, sector, quality, continuity, and equity of maternal care in Kenya? The findings from the systematic review suggest that there is substantial heterogeneity in the way that the private health sector is defined in scientific literature, making it difficult to compare estimates of private sector health provision. The qualitative study reveals that Kenya’s pluralistic health system results from the confluence of many historical, social, political, and economic factors and effective lobbying by the private for-profit sector. Finally, the three quasi-experimental studies highlight a complex set of outcomes resulting from user fee removal policies and the safe motherhood voucher program in Kenya. The 10/20 policy was associated with positive effects on the timing and number of ANC visits; however, these improvements were unrelated to use of the public primary care facilities that the policy targeted. The voucher program increased use of facility-based delivery care among poor women; however, it had no impact on use of four or more ANC visits or postnatal care. After the free maternity services policy was introduced, the voucher program no longer improved use of facility-based delivery among the poor; however, use of the private sector remained much higher in voucher counties. Both the voucher program and insurance coverage had positive impacts on continuity of maternal care for poor women, while introduction of the free maternity services policy did not. Many factors affect women’s use of maternal health services beyond the cost of care. Making services free in the public sector is not sufficient to eliminate disparities in access to health services; policymakers must therefore simultaneously address both financial and nonfinancial barriers to service use. Health financing strategies involving private providers have the potential to equitably increase service use and continuity, provided that the cost of care is subsidized for users with the lowest ability to pay

Comparing the use and content of antenatal care in adolescent and older first-time mothers in 13 countries of west Africa: a cross-sectional analysis of Demographic and Health Surveys

Background West Africa has the highest proportion of married adolescents, and the highest adolescent childbirth rate and maternal death rate in sub-Saharan Africa. However, few studies have focused on the type and quality of health care accessed by pregnant young women in countries in this subregion. Methods We obtained data from Demographic and Health Surveys done between 2010 and 2014, to compare the use, timing, source, and components of antenatal care between adolescent and older first-time mothers in 13 west African countries. The sample included primiparous women who were aged 15–49 years with a livebirth in the 5-year survey recall period, and women were assigned to one of three groups on the basis of age at the time of childbirth: adolescent (10–19 years), young adults (20–24 years), or adults (25 years or older). We calculated the percentage of women who: attended at least one antenatal care visit, completed at least one visit during the first trimester of pregnancy, attended four or more appointments in antenatal care, and received four components of antenatal care (blood pressure measurement, urine tests, blood tests, and information on complications), as well as the sector where the women received care. We primarily report the comparison between adolescents and young adults. Findings In 2016, we acquired data from the Demographic Health Surveys from 13 west African countries between 2010 and 2014 on primiparous women. The study sample was 19 211 women, of whom 10 025 (52%) were adolescents, 6099 (32%) were young adults, and 3087 (16%) were adults. Overall, 17 386 (91%) of 19 211 first-time mothers made use of antenatal care facilities on at least one occasion. 3597 (41%) of 8741 adolescents compared with 8202 (47%) of all 17 386 women began the use of antenatal care during the first trimester. Across west Africa, 5430 (62%) of 8741 adolescents had four or more antenatal care visits compared with 4067 (71%) of 5717 young adults and 2358 (81%) of 2928 adults. Of those who had four or more visits to antenatal care, 2779 (51%) of 5430 adolescents received all the antenatal care components examined compared with 2488 (61%) of 4067 young adults and 1600 (68%) of 2358 adults. Although most women received antenatal care in the public sector, in nine of the 13 countries, the proportion of women that used the private sector was higher in older mothers. Interpretation Although a large percentage of west African adolescents use some antenatal care for their first birth, they seek care later, make fewer visits during pregnancy, and receive fewer components of care than older first-time mothers. Governments must ensure the pregnancy care accessed by adolescent mothers is of high quality and tailored to meet their needs

Cerebellar roots of aggression in violent psychopathic offenders: evidence from structural neuroimaging studies

Investigations of structural brain abnormalities in antisocial personality disorder and psychopathy associated with aggression have focused on prefrontal, limbic, and paralimbic regions. In this narrative review, a series of structural neuroanatomical studies are discussed, which points toward an important role of the cerebellum in antisocial and aggressive behavior. Across the reviewed studies, volumetric reduction of the vermis and right posterior cerebellum was a consistent finding in violent psychopathic offenders. The observations agree with results in healthy volunteers, which show that volumes of the vermis and right cerebellar hemisphere are correlated with impulsivity and aggressive behavior. Deviations in cerebellar volumes in violent psychopathic offenders are proposed to be part of a deficient neural circuit implicated in emotion regulation and executive functions

Garden varieties: how attractive are recommended garden plants to butterflies?

One way the public can engage in insect conservation is through wildlife gardening, including the growing of insect-friendly flowers as sources of nectar. However, plant varieties differ in the types of insects they attract. To determine which garden plants attracted which butterflies, we counted butterflies nectaring on 11 varieties of summer-flowering garden plants in a rural garden in East Sussex, UK. These plants were all from a list of 100 varieties considered attractive to British butterflies, and included the five varieties specifically listed by the UK charity Butterfly Conservation as best for summer nectar. A total of 2659 flower visits from 14 butterfly and one moth species were observed. We performed a principal components analysis which showed contrasting patterns between the species attracted to Origanum vulgare and Buddleia davidii. The “butterfly bush” Buddleia attracted many nymphalines, such as the peacock, Inachis io, but very few satyrines such as the gatekeeper, Pyronia tithonus, which mostly visited Origanum. Eupatorium cannibinum had the highest Simpson’s Diversity score of 0.75, while Buddleia and Origanum were lower, scoring 0.66 and 0.50 respectively. No one plant was good at attracting all observed butterfly species, as each attracted only a subset of the butterfly community. We conclude that to create a butterfly-friendly garden, a variety of plant species are required as nectar sources for butterflies. Furthermore, garden plant recommendations can probably benefit from being more precise as to the species of butterfly they attract

The Reinforcing Therapist Performance (RTP) experiment: Study protocol for a cluster randomized trial

<p>Abstract</p> <p>Background</p> <p>Rewarding provider performance has been recommended by the Institute of Medicine as an approach to improve the quality of treatment, yet little empirical research currently exists that has examined the effectiveness and cost-effectiveness of such approaches. The aim of this study is to test the effectiveness and cost-effectiveness of providing monetary incentives directly to therapists as a method to improve substance abuse treatment service delivery and subsequent client treatment outcomes.</p> <p>Design</p> <p>Using a cluster randomized design, substance abuse treatment therapists from across 29 sites were assigned by site to either an implementation as usual (IAU) or pay-for-performance (P4P) condition.</p> <p>Participants</p> <p>Substance abuse treatment therapists participating in a large dissemination and implementation initiative funded by the Center for Substance Abuse Treatment.</p> <p>Intervention</p> <p>Therapists in both conditions received comprehensive training and ongoing monitoring, coaching, and feedback. However, those in the P4P condition also were given the opportunity to earn monetary incentives for achieving two sets of measurable behaviors related to quality implementation of the treatment.</p> <p>Outcomes</p> <p>Effectiveness outcomes will focus on the impact of the monetary incentives to increase the proportion of adolescents who receive a targeted threshold level of treatment, months that therapists demonstrate monthly competency, and adolescents who are in recovery following treatment. Similarly, cost-effectiveness outcomes will focus on cost per adolescent receiving targeted threshold level of treatment, cost per month of demonstrated competence, and cost per adolescent in recovery.</p> <p>Trial Registration</p> <p>Trial Registration Number: NCT01016704</p

HIV-1 Packaging Visualised by In-Gel SHAPE.

HIV-1 packages two copies of its gRNA into virions via an interaction with the viral structural protein Gag. Both copies and their native RNA structure are essential for virion infectivity. The precise stepwise nature of the packaging process has not been resolved. This is largely due to a prior lack of structural techniques that follow RNA structural changes within an RNA-protein complex. Here, we apply the in-gel SHAPE (selective 2'OH acylation analysed by primer extension) technique to study the initiation of HIV-1 packaging, examining the interaction between the packaging signal RNA and the Gag polyprotein, and compare it with that of the NC domain of Gag alone. Our results imply interactions between Gag and monomeric packaging signal RNA in switching the RNA conformation into a dimerisation-competent structure, and show that the Gag-dimer complex then continues to stabilise. These data provide a novel insight into how HIV-1 regulates the translation and packaging of its genome.This work was funded by an Eric Reid fund for Methodology grant from the Biochemical Society (to JCK), UK Medical Research Council, Grant/Award Number: MR/N022939/1 (to AML and JCK). AMLL is supported by the Clinical Academic Reserve and his laboratory by the NIHR Cambridge BRC (Grant RCAG/18). Research in the Kappei laboratory was supported by the National Research Foundation Singapore and the Singapore Ministry of Education under its Re-search Centres of Excellence initiative

HIV-1 Packaging Visualised by In-Gel SHAPE.

HIV-1 packages two copies of its gRNA into virions via an interaction with the viral structural protein Gag. Both copies and their native RNA structure are essential for virion infectivity. The precise stepwise nature of the packaging process has not been resolved. This is largely due to a prior lack of structural techniques that follow RNA structural changes within an RNA-protein complex. Here, we apply the in-gel SHAPE (selective 2'OH acylation analysed by primer extension) technique to study the initiation of HIV-1 packaging, examining the interaction between the packaging signal RNA and the Gag polyprotein, and compare it with that of the NC domain of Gag alone. Our results imply interactions between Gag and monomeric packaging signal RNA in switching the RNA conformation into a dimerisation-competent structure, and show that the Gag-dimer complex then continues to stabilise. These data provide a novel insight into how HIV-1 regulates the translation and packaging of its genome.This work was funded by an Eric Reid fund for Methodology grant from the Biochemical Society (to JCK), UK Medical Research Council, Grant/Award Number: MR/N022939/1 (to AML and JCK). AMLL is supported by the Clinical Academic Reserve and his laboratory by the NIHR Cambridge BRC (Grant RCAG/18). Research in the Kappei laboratory was supported by the National Research Foundation Singapore and the Singapore Ministry of Education under its Re-search Centres of Excellence initiative

Initiation and continuity of maternal healthcare: examining the role of vouchers and user-fee removal on maternal health service use in Kenya

This study explores the relationship between two health financing initiatives on women's progression through the maternal health continuum in Kenya: a subsidized reproductive health voucher programme (2006-16) and the introduction of free maternity services in all government facilities (2013). Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the voucher programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation (first visit within the first trimester of pregnancy), (2) receiving continuous care (1+ ANC, facility birth, 1+ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4+ ANC, facility birth, 1+ PNC, with first check occurring within 48 h of delivery). Full implementation of the voucher programme was positively associated with receiving continuous care among users of 1+ ANC [interaction term adjusted odds ratio (aOR): 1.33, P = 0.014]. Early ANC initiation (aOR: 1.32, P = 0.001) and use of private sector ANC (aOR: 1.93, P < 0.001) were also positively associated with use of continuous care among ANC users. Among continuous care users, early ANC was associated with increased odds of completing the maternal health pathway as recommended (aOR: 3.80, P < 0.001). Higher parity was negatively associated with all three outcomes, while having health insurance was positively associated with each outcome. The impact of other sociodemographic factors such as maternal age, education, wealth quintile, urban residence, and employment varied by outcome; however, the findings generally suggest that marginalized women faced greater barriers to early ANC initiation and continuity of care. Health financing and women's timing and source of ANC are strongly related to their subsequent progression through the maternal health pathway. To increase continuity of care and improve maternal health outcomes, policymakers must therefore focus on equitably reducing financial and other barriers to care seeking and improving quality of care throughout the continuum

Evaluating the impact of a maternal health voucher programme on service use before and after the introduction of free maternity services in Kenya: a quasi-experimental study

INTRODUCTION: From 2006 to 2016, the Government of Kenya implemented a reproductive health voucher programme in select counties, providing poor women subsidised access to public and private sector care. In June 2013, the government introduced a policy calling for free maternity services to be provided in all public facilities. The concurrent implementation of these interventions presents an opportunity to provide new insights into how users adapt to a changing health financing and service provision landscape. METHODS: We used data from three cross-sectional surveys to assess changes over time in use of 4+ antenatal care visits, facility delivery, postnatal care and maternal healthcare across the continuum among a sample of predominantly poor women in six counties. We conducted a difference-in-differences analysis to estimate the impact of the voucher programme on these outcomes, and whether programme impact changed after free maternity services were introduced. RESULTS: Between the preintervention/roll-out phase and full implementation, the voucher programme was associated with a 5.5% greater absolute increase in use of facility delivery and substantial increases in use of the private sector for all services. After free maternity services were introduced, the voucher programme was associated with a 5.7% higher absolute increase in use of the recommended package of maternal health services; however, disparities in access to facility births between voucher and comparison counties declined. Increased use of private sector services by women in voucher counties accounts for their greater access to care across the continuum. CONCLUSIONS: Our findings show that the voucher programme is associated with a modest increase in women’s use of the full continuum of maternal health services at the recommended timings after free maternity services were introduced. The greater use of private sector services in voucher counties also suggests that there is need to expand women’s access to acceptable and affordable providers

Advantages and Limitations of Commercially Available Electrocuting Grids for Studying Mosquito Behaviour.

Mosquito feeding behaviour plays a major role in determining malaria transmission intensity and the impact of specific prevention measures. Human Landing Catch (HLC) is currently the only method that can directly and consistently measure the biting rates of anthropophagic mosquitoes, both indoors and outdoors. However, this method exposes the participant to mosquito-borne pathogens, therefore new exposure-free methods are needed to replace it. Commercially available electrocuting grids (EGs) were evaluated as an alternative to HLC using a Latin Square experimental design in Dar es Salaam, Tanzania. Both HLC and EGs were used to estimate the proportion of human exposure to mosquitoes occurring indoors (πi), as well as its two underlying parameters: the proportion of mosquitoes caught indoors (Pi) and the proportion of mosquitoes caught between the first and last hour when most people are indoors (Pfl). HLC and EGs methods accounted for 69% and 31% of the total number of female mosquitoes caught respectively and both methods caught more mosquitoes outdoors than indoors. Results from the gold standard HLC suggest that An. gambiae s.s. in Dar es Salaam is neither exophagic nor endophagic (Pi ≈ 0.5), whereas An. arabiensis is exophagic (Pi < < 0.5). Both species prefer to feed after 10 pm when most people are indoors (Pfl > >0.5). EGs yielded estimates of Pi for An. gambiae s.s., An. arabiensis and An. coustani, that were approximately equivalent to those with HLC but significantly underestimated Pfl for An. gambiae s.s. and An. coustani. The relative sampling sensitivity of EGs declined over the course of the night (p ≤ 0.001) for all mosquito taxa except An. arabiensis. Commercial EGs sample human-seeking mosquitoes with high sensitivity both indoors and outdoors and accurately measure the propensity of Anopheles malaria vectors to bite indoors rather than outdoors. However, further modifications are needed to stabilize sampling sensitivity over a full nocturnal cycle so that they can be used to survey patterns of human exposure to mosquitoes