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

Quality of comprehensive emergency obstetric care through the lens of clinical documentation on admission to labour ward

Background: Clinical documentation gives a chronological order of procedures and activities that a patient is given during their management.Objective: To determine the level of quality of comprehensive emergency obstetric care, through the lens of clinical documentation of process indicators of selected emergency obstetric conditions that mostly cause maternal mortality on admission to labour wardDesign: Multi-site cross sectional survey.Setting: Twenty two Government Hospitals in Kenya with capacity to offer comprehensive emergency obstetric care.Subjects: Process variables were abstracted from patient’ case records with a diagnosis of normal vaginal delivery, obstetric haemorrhage, severe pre eclampsia/eclampsia and emergency cesarean section.Results: Availability of structure indicators were graded excellent and good except for long gloves, misoprostol, ergometrin and parenteral cefuroxime that were graded low. A total of 1,216 records were abstracted for process analysis. The median (IQR) for the: six variables of obstetric history was five (4-5); five variables of antenatal profile was four (1-5); five variables of vital signs documentation was three (2-4); five variables for obstetric exam was four (4-5); seven variables of vaginal examination one (0-2); ten variables for partograph was seven (2-9); five variables for obstetric hemorrhage was three (2-4) and eleven variables for severe pre-eclampsia/eclampsia was five (3-6). The median (IQR) from decision-to-operate to caesarean section was three (2-4) hours.Conclusion: Quality of emergency obstetric care based on documentation depicts inadequacy. There is an urgent need to objectively address the need for proper clinical documentation as an indicator of quality performance

Assessing the ability of health information systems in hospitals to support evidence-informed decisions in Kenya.

BACKGROUND: Hospital management information systems (HMIS) is a key component of national health information systems (HIS), and actions required of hospital management to support information generation in Kenya are articulated in specific policy documents. We conducted an evaluation of core functions of data generation and reporting within hospitals in Kenya to facilitate interpretation of national reports and to provide guidance on key areas requiring improvement to support data use in decision making. DESIGN: The survey was a cross-sectional, cluster sample study conducted in 22 hospitals in Kenya. The statistical analysis was descriptive with adjustment for clustering. RESULTS: Most of the HMIS departments complied with formal guidance to develop departmental plans. However, only a few (3/22) had carried out a data quality audit in the 12 months prior to the survey. On average 3% (range 1-8%) of the total hospital income was allocated to the HMIS departments. About half of the records officer positions were filled and about half (13/22) of hospitals had implemented some form of electronic health record largely focused on improving patient billing and not linked to the district HIS. Completeness of manual patient registers varied, being 90% (95% CI 80.1-99.3%), 75.8% (95% CI 68.7-82.8%), and 58% (95% CI 50.4-65.1%) in maternal child health clinic, maternity, and pediatric wards, respectively. Vital events notification rates were low with 25.7, 42.6, and 71.3% of neonatal deaths, infant deaths, and live births recorded, respectively. Routine hospital reports suggested slight over-reporting of live births and under-reporting of fresh stillbirths and neonatal deaths. CONCLUSIONS: Study findings indicate that the HMIS does not deliver quality data. Significant constraints exist in data quality assurance, supervisory support, data infrastructure in respect to information and communications technology application, human resources, financial resources, and integration

Assessing the ability of health information systems in hospitals to support evidence-informed decisions in Kenya.

BACKGROUND: Hospital management information systems (HMIS) is a key component of national health information systems (HIS), and actions required of hospital management to support information generation in Kenya are articulated in specific policy documents. We conducted an evaluation of core functions of data generation and reporting within hospitals in Kenya to facilitate interpretation of national reports and to provide guidance on key areas requiring improvement to support data use in decision making. DESIGN: The survey was a cross-sectional, cluster sample study conducted in 22 hospitals in Kenya. The statistical analysis was descriptive with adjustment for clustering. RESULTS: Most of the HMIS departments complied with formal guidance to develop departmental plans. However, only a few (3/22) had carried out a data quality audit in the 12 months prior to the survey. On average 3% (range 1-8%) of the total hospital income was allocated to the HMIS departments. About half of the records officer positions were filled and about half (13/22) of hospitals had implemented some form of electronic health record largely focused on improving patient billing and not linked to the district HIS. Completeness of manual patient registers varied, being 90% (95% CI 80.1-99.3%), 75.8% (95% CI 68.7-82.8%), and 58% (95% CI 50.4-65.1%) in maternal child health clinic, maternity, and pediatric wards, respectively. Vital events notification rates were low with 25.7, 42.6, and 71.3% of neonatal deaths, infant deaths, and live births recorded, respectively. Routine hospital reports suggested slight over-reporting of live births and under-reporting of fresh stillbirths and neonatal deaths. CONCLUSIONS: Study findings indicate that the HMIS does not deliver quality data. Significant constraints exist in data quality assurance, supervisory support, data infrastructure in respect to information and communications technology application, human resources, financial resources, and integration

Adoption of recommended practices and basic technologies in a low-income setting

Objective: In global health considerable attention is focused on the search for innovations; however, reports tracking their adoption in routine hospital settings from low-income countries are absent. Design and setting: We used data collected on a consistent panel of indicators during four separate cross-sectional, hospital surveys in Kenya to track changes over a period of 11 years (2002-2012). Main outcome measures: Basic resource availability, use of diagnostics and uptake of recommended practices. Results: There appeared little change in availability of a panel of 28 basic resources (median 71% in 2002 to 82% in 2012) although availability of specific feeds for severe malnutrition and vitamin K improved. Use of blood glucose and HIV testing increased but remained inappropriately low throughout. Commonly (malaria) and uncommonly (lumbar puncture) performed diagnostic tests frequently failed to inform practice while pulse oximetry, a simple and cheap technology, was rarely available even in 2012. However, increasing adherence to prescribing guidance occurred during a period from 2006 to 2012 in which efforts were made to disseminate guidelines. Conclusions: Findings suggest changes in clinical practices possibly linked to dissemination of guidelines at reasonable scale. However, full availability of basic resources was not attained and major gaps likely exist between the potential and actual impacts of simple diagnostics and technologies representing problems with availability, adoption and successful utilisation. These findings are relevant to debates on scaling up in low-income settings and to those developing novel therapeutic or diagnostic interventions

Robust Handwritten Text Recognition in Scarce Labeling Scenarios : Disentanglement, Adaptation and Generation

Els documents escrits a mà no només es conserven en arxius històrics, sinó que també s'utilitzen àmpliament en documents administratius, com ara xecs o formularis. Amb l'auge de de l'anomenat aprenentatge profund (Deep Learning), s'ha aconseguit un bon rendiment en conjunts de dades específics per al reconeixement de text manuscrit. Tot i això, encara és difícil resoldre casos d'ús reals a causa de la variació entre estils d'escriptura de diferents escriptors i el fet de tenir dades etiquetades limitades. Per tant, es requereix explorar arquitectures de reconeixement d'escriptura més sòlides així com proposar mètodes per disminuir la bretxa entre conjunts de dades font i objectiu de manera no supervisada. En aquesta tesi, en primer lloc, explorem noves arquitectures per al reconeixement de text manuscrit, un mètode Sequence-to-Sequence amb mecanisme d'atenció i un mètode basat en transformadors no recurrents. En segon lloc, ens centrem en la disminució de la bretxa de rendiment entre les dades d'origen i les de destinació de manera no supervisada. Finalment, proposem un grup de mètodes generatius per a imatges de text manuscrits, que es poden utilitzar per augmentar el conjunt d'entrenament per obtenir un reconeixement més robust. A més, simplement modificant el mètode generatiu i unint-lo amb un reconeixedor, acabem amb un mètode de desenredament eficaç per destil·lar contingut textual d'estils d'escriptura a mà per aconseguir un rendiment de reconeixement generalitzat. Superem el rendiment dels reconeixedors de text manuscrit de l'estat de l'art en els resultats experimentals entre diferents conjunts de dades científics i industrials, que demostren l'eficàcia dels mètodes proposats. Tant ell reconeixement no recurrent com el mètode de desenredament són les primeres contribucions al camp del reconeixement d'escriptura a mà. A més, hem esbossat les línies de recerca potencials, que serien interessants explorar en el futur.Los documentos manuscritos no solo se conservan en archivos históricos, sino que también se usan ampliamente en documentos administrativos como cheques y reclamaciones. Con el auge de las redes neuronales profundas, muchas técnicas del estado del arte han obtenido un buen rendimiento en conjuntos de datos específicos para el reconocimiento de texto manuscrito (HTR). Sin embargo, los casos de uso reales todavía son un desafío debido a la variabilidad de estilos de escritura de diferentes escritores y la cantidad limitada de datos etiquetados. Por lo tanto, es necesario explorar tanto arquitecturas para reconocimiento de texto manuscrito más robustas como proponer métodos para disminuir la brecha entre los datos de origen y destino de una manera no supervisada. En esta tesis, en primer lugar, exploramos arquitecturas novedosas para el HTR, desde el método secuencia-a-secuencia (Seq2Seq) con mecanismo de atención, hasta el método no recurrente basado en Transformers. En segundo lugar, nos centramos en reducir la brecha de rendimiento entre los datos de origen y de destino mediante métodos no supervisados. Finalmente, proponemos un grupo de métodos generativos para imágenes de texto manuscrito, que pueden usarse para aumentar el conjunto de entrenamiento y obtener un reconocedor más robusto. Además, simplemente modificando el método generativo y uniéndolo con un reconocedor, obtenemos un método eficaz para destilar el contenido textual de los estilos de escritura para lograr un rendimiento de reconocimiento generalizado. En resultados experimentales obtenemos rendimientos en HTR que superan los del estado del arte en diferentes conjuntos de datos científicos e industriales, los cuales demuestran la efectividad de los métodos propuestos. Hasta donde sabemos, el reconocedor no recurrente y el método de para destilar son contribuciones originales en el campo de reconocimiento de texto manuscrito. Finalmente, hemos esbozado posibles líneas de investigación que sería interesante explorar en el futuro.Handwritten documents are not only preserved in historical archives but also widely used in administrative documents such as cheques and claims. With the rise of the deep learning era, many state-of-the-art approaches have achieved good performance on specific datasets for Handwritten Text Recognition (HTR). However, it is still challenging to solve real use cases because of the varied handwriting styles across different writers and the limited labeled data. Thus, both exploring a more robust handwriting recognition architectures and proposing methods to diminish the gap between the source and target data in an unsupervised way are demanded. In this thesis, firstly, we explore novel architectures for HTR, from Sequence-to-Sequence (Seq2Seq) method with attention mechanism to non-recurrent Transformer-based method. Secondly, we focus on diminishing the performance gap between source and target data in an unsupervised way. Finally, we propose a group of generative methods for handwritten text images, which could be utilized to increase the training set to obtain a more robust recognizer. In addition, by simply modifying the generative method and joining it with a recognizer, we end up with an effective disentanglement method to distill textual content from handwriting styles so as to achieve a generalized recognition performance. We outperform state-of-the-art HTR performances in the experimental results among different scientific and industrial datasets, which prove the effectiveness of the proposed methods. To the best of our knowledge, the non-recurrent recognizer and the disentanglement method are the first contributions in the handwriting recognition field. Furthermore, we have outlined the potential research lines, which would be interesting to explore in the future.Universitat Autònoma de Barcelona. Programa de Doctorat en Informàtic

Adoption of recommended practices and basic technologies in a low-income setting.

OBJECTIVE: In global health considerable attention is focused on the search for innovations; however, reports tracking their adoption in routine hospital settings from low-income countries are absent. DESIGN AND SETTING: We used data collected on a consistent panel of indicators during four separate cross-sectional, hospital surveys in Kenya to track changes over a period of 11 years (2002-2012). MAIN OUTCOME MEASURES: Basic resource availability, use of diagnostics and uptake of recommended practices. RESULTS: There appeared little change in availability of a panel of 28 basic resources (median 71% in 2002 to 82% in 2012) although availability of specific feeds for severe malnutrition and vitamin K improved. Use of blood glucose and HIV testing increased but remained inappropriately low throughout. Commonly (malaria) and uncommonly (lumbar puncture) performed diagnostic tests frequently failed to inform practice while pulse oximetry, a simple and cheap technology, was rarely available even in 2012. However, increasing adherence to prescribing guidance occurred during a period from 2006 to 2012 in which efforts were made to disseminate guidelines. CONCLUSIONS: Findings suggest changes in clinical practices possibly linked to dissemination of guidelines at reasonable scale. However, full availability of basic resources was not attained and major gaps likely exist between the potential and actual impacts of simple diagnostics and technologies representing problems with availability, adoption and successful utilisation. These findings are relevant to debates on scaling up in low-income settings and to those developing novel therapeutic or diagnostic interventions