Ethical issues evolving from patients’ perspectives on compulsory screening for syphilis and voluntary screening for cervical cancer in Kenya

BACKGROUND: Public health aims to provide universal safety and progressive opportunities to populations to realise their highest level of health through prevention of disease, its progression or transmission. Screening asymptomatic individuals to detect early unapparent conditions is an important public health intervention strategy. It may be designed to be compulsory or voluntary depending on the epidemiological characteristics of the disease. Integrated screening, including for both syphilis and cancer of the cervix, is a core component of the national reproductive health program in Kenya. Screening for syphilis is compulsory while it is voluntary for cervical cancer. Participants’ perspectives of either form of screening approach provide the necessary contextual information that clarifies mundane community concerns. METHODS: Focus group discussions with female clients screened for syphilis and cancer of the cervix were conducted to elicit their perspectives of compulsory and voluntary screening. The discussions were audiotaped, transcribed and thematic content analysis performed manually to explore emerging ethics issues. RESULTS: The results indicate that real ethical challenges exist in either of the approaches. Also, participants were more concerned about the benefits of the procedure and whether their dignity is respected than the compulsoriness of screening per se. The implication is for the policy makers to clarify in the guidelines how to manage ethical challenges, while at the operational level, providers need to be judicious to minimize potential harms participants and families when screening for disease in women. CONCLUSIONS: The context for mounting screening as a public health intervention and attendant ethical issues may be more complex than hitherto perceived. Interpreting emerging ethics issues in screening requires more nuanced considerations of individuals’ contextual experiences since these may be contradictory to the policy position. In considering mounting screening for Syphilis and cervical cancer as a public heal intervention, the community interests and perspectives should be inculcated into the program. Population lack of information on procedures may influence adversely the demand for screening services by the individuals at risk or the community as a collective agent

Patient-level cost of home- and facility-based child pneumonia treatment in Suba Sub County, Kenya.

BACKGROUND:Globally, pneumonia accounted for 16% of deaths among children under 5 years of age and was one of the major causes of death overall in 2018. Kenya is ranked among the top 15 countries with regard to pneumonia prevalence and contributed approximately 74% of the world's annual pneumonia cases in 2018. Unfortunately, less than 50% of children with pneumonia receive appropriate antibiotics for treatment. Homa-Bay County implemented pneumonia community case management utilizing community health workers, as recommended by the World Health Organization (WHO), in 2014. However, since implementation of the program, the relative patient-level cost of home-based and facility-based treatment of pneumonia, as well as the main drivers of these costs in Suba Subcounty, remain uncertain. Therefore, the main objective of this study was to compare the patient-level costs of home based treatment of pneumonia by a community health worker with those of health facility-based treatment. METHODS AND FINDINGS:Using a cross-sectional study design, a structured questionnaire was used to collect quantitative data from 208 caregivers on the direct costs (consultation, medicine, transportation) and indirect costs (opportunity cost) of pneumonia treatment. The average household cost for the community managed patients was KSH 122.65 ($1.29) compared with KSh 447.46 ($4.71), a 4-fold difference, for those treated at the health facility. The largest cost drivers for home treatment and health facility treatment were opportunity costs (KSH 88.25 ($0.93)) and medicine costs (KSH 126.16 ($ 1.33)), respectively. CONCLUSION:This study demonstrates that the costs incurred for home-based pneumonia management are considerably lower compared to those incurred for facility-based management. Opportunity costs (caregiver time and forgone wages) and the cost of medication were the key cost-drivers in the management of pneumonia at the health facility and at home, respectively. These findings emphasize the need to strengthen and scale community case management to overcome barriers and delays in accessing the correct treatment for pneumonia for sick children under 5 years of age

Voluntary medical male circumcision scale-up in Nyanza, Kenya: evaluating technical efficiency and productivity of service delivery.

BACKGROUND:Voluntary medical male circumcision (VMMC) service delivery is complex and resource-intensive. In Kenya's context there is still paucity of information on resource use vis-à-vis outputs as programs scale up. Knowledge of technical efficiency, productivity and potential sources of constraints is desirable to improve decision-making. OBJECTIVE:To evaluate technical efficiency and productivity of VMMC service delivery in Nyanza in 2011/2012 using data envelopment analysis. DESIGN:Comparative process evaluation of facilities providing VMMC in Nyanza in 2011/2012 using output orientated data envelopment analysis. RESULTS:Twenty one facilities were evaluated. Only 1 of 7 variables considered (total elapsed operation time) significantly improved from 32.8 minutes (SD 8.8) in 2011 to 30 minutes (SD 6.6) in 2012 (95%CI = 0.0350-5.2488; p = 0.047). Mean scale technical efficiency significantly improved from 91% (SD 19.8) in 2011 to 99% (SD 4.0) in 2012 particularly among outreach compared to fixed service delivery facilities (CI -31.47959-4.698508; p = 0.005). Increase in mean VRS technical efficiency from 84% (SD 25.3) in 2011 and 89% (SD 25.1) in 2012 was not statistically significant. Benchmark facilities were #119 and #125 in 2011 and #103 in 2012. Malmquist Productivity Index (MPI) at fixed facilities declined by 2.5% but gained by 4.9% at outreach ones by 2012. Total factor productivity improved by 83% (p = 0.032) in 2012, largely due to progress in technological efficiency by 79% (p = 0.008). CONCLUSIONS:Significant improvement in scale technical efficiency among outreach facilities in 2012 was attributable to accelerated activities. However, ongoing pure technical inefficiency requires concerted attention. Technological progress was the key driver of service productivity growth in Nyanza. Incorporating service-quality dimensions and using stepwise-multiple criteria in performance evaluation enhances comprehensiveness and validity. These findings highlight site-level resource use and sources of variations in VMMC service productivity, which are important for program planning

Service quality ranking by cases in 2011 and 2012 and by facility in 2012.

<p>Service quality ranking by cases in 2011 and 2012 and by facility in 2012.</p

Scree plot showing distribution of factors by their eigenvalues.

<p>A Scree plot of eigenvalues of the unrotated factors displaying an ‘elbow’ of the plot (shown by the red arrow). This point of the curve represents the threshold chosen for retention of the initial factors extracted from the observed variables and which maximize the variance accounted for. Three factors, each respectively with eigenvalues of 5.78; 4.29; 2.99 were retained. These factors cumulatively accounted for 29.1% of the total variance (12.9%; 9.5%; 6.7%) with final communality estimates being 13.06. The shallow “scree” distal to the arrow demonstrates small extent of variance accounted for by the subsequent minor factors, which were deleted.</p

Overall facility ranking by weighted quality scores.

<p>Overall facility ranking by weighted quality scores.</p

Facility actual production inputs and outputs by year based on output oriented VRS DEA model.

<p>Facility actual production inputs and outputs by year based on output oriented VRS DEA model.</p

Table showing model input and output variables and their definitions.

<p>Table showing model input and output variables and their definitions.</p

VMMC provider profile in the four SYMMACS countries.

<p>[A] Primary providers perform VMMC (removes foreskin).</p><p>[B] Secondary providers assist the primary surgical provider.</p><p>[C] full time defined as dedicated ≥90% of working hours to VMMC.</p