A feasibility study using time-driven activity-based costing as a management tool for provider cost estimation: lessons from the national TB control program in Zimbabwe in 2018.

BACKGROUND: Insufficient cost data and limited capacity constrains the understanding of the actual resources required for effective TB control. This study used process maps and time-driven activity-based costing to document TB service delivery processes. The analysis identified the resources required to sustain TB services in Zimbabwe, as well as several opportunities for more effective and efficient use of available resources. METHODS: A multi-disciplinary team applied time-driven activity-based costing (TDABC) to develop process maps and measure the cost of clinical pathways used for Drug Susceptible TB (DS-TB) at urban polyclinics, rural district and provincial hospitals, and community based targeted screening for TB (Tas4TB). The team performed interviews and observations to collect data on the time taken by health care worker-patient pairs at every stage of the treatment pathway. The personnel's practical capacity and capacity cost rates were calculated on five cost domains. An MS Excel model calculated diagnostic and treatment costs. FINDINGS: Twenty-five stages were identified in the TB care pathway across all health facilities except for community targeted screening for TB. Considerable variations were observed among the facilities in how health care professionals performed client registration, taking of vital signs, treatment follow-up, dispensing medicines and processing samples. The average cost per patient for the entire DS-TB care was USD324 with diagnosis costing USD69 and treatment costing USD255. The average cost for diagnosis and treatment was higher in clinics than in hospitals (USD392 versus USD256). Nurses in clinics were 1.6 time more expensive than in hospitals. The main cost components were personnel (USD130) and laboratory (USD119). Diagnostic cost in Tas4TB was twice that of health facility setting (USD153 vs USD69), with major cost drivers being demand creation (USD89) and sputum specimen transportation (USD5 vs USD3). CONCLUSION: TDABC is a feasible and effective costing and management tool in low-resource settings. The TDABC process maps and treatment costs revealed several opportunities for innovative improvements in the NTP under public health programme settings. Re-engineering laboratory testing processes and synchronising TB treatment follow-up with antiretroviral treatments could produce better and more uniform TB treatments at significantly lower cost in Zimbabwe

Influence of Selected Socio-Economic Factors on Crop Productivity under Irrigated Agriculture among Kimira-Oluch Smallholder Farmers of Homa Bay County, Kenya

Irrigation technology plays a critical role in enhancing agricultural productivity globally. For the last ten years, the availability of water for irrigation has been rapidly declining yet the demand for water for irrigation has been on arise. The introduction of irrigation technologies as immediate interventions for crop productivity has proved to be effective in many countries and most likely has changed the phenomenon to a more reliable and sustainable agricultural production. Despite many efforts by the Kenyan government to improve the country’s agricultural sector, still there is low crop productivity due to the continued practice of rainfed agriculture. The main objective of this study was to determine the influence of selected socio-economic factors that is the attitude towards the introduction of irrigation intervention, Irrigation technologies, Gender participation, Age of the participant, Household income, and Level of education on crop productivity among Kimira-Oluch smallholder farmers in Homa Bay County, Kenya. A survey methodology with an Ex-post facto research design was used with a sampling frame consisting of 340 smallholders. Data were collected through interview schedules administered to participants in irrigated agriculture and Non-participants (rainfed agriculture). Inferential statistics used involves multiple regression analysis and two-way ANOVA. The hypothesis was tested at a 5% level of significance and the results revealed an absolute value of correlation coefficient of 0.823 which indicates that there is a high correlation between the crop productivity and selected socio-economic factors that is (ATT, IRT, GP, HI, AR and ELR). The findings further revealed that R2= 0.714 of the proportionate variation of the model an indication that, the selected socio-economic factors can predict 71.4% of crop productivity and the other variables not included in the model can only predict 29.6% of productivity. By using analysis of variance (ANOVA) the findings revealed that the regression model predicts that there is a significant improvement in crop productivity and the farming system as well. This was revealed by the F-ratio of 71.83 indicating a significant relationship at a p-value of= 0 .000. The model will be of greater use in determining the influence of socio-economic factors on crop productivity in other regions without necessary undergoing the full research processes thus reducing the research expenses by almost half

Effect of Combined Metakaolin and Basalt Powder Additions to Laterite-Based Geopolymers Activated by Rice Husk Ash (RHA)/NaOH Solution

The present study deals with the use of locally prepared rice husk ash (RHA)-based sodium silicate for alkaline activation of laterites (uncalcined (LNW) and calcined (LCA)). RHA-based activator (SSR) was prepared by adding as-collected RHA to 6 M NaOH at a solid/liquid mass ratio of 0.56. The various proportions of metakaolin (MK) and basalt powder (BA) influenced the final properties of the geopolymer products. After 28 days of curing at room temperature, XRD, SEM and FT-IR analyses were used to study the evolution phases. Uncalcined laterite-based formulations showed their highest compressive strength at 29.86 MPa with 20 wt.% of MK, whereas calcined ones showed the most elevated strength at 47.02 MPa, with the addition of 25 wt.% MK. Further additions above these thresholds tend to reduce strength and increase setting time. Substitution of calcined laterite with basalt powder permitted to control the porosity of samples at low values with the consequent reduction of strength. In general, the water absorption and apparent porosity decrease with addition of metakaolin in raw laterite-based formulations and relatively decrease with addition of basalt powder in calcined laterite-based formulations, while bulk density remains relatively constant. The locally produced RHA-based alkaline activator is efficient for laterite geopolymerization, resulting in products with robust mechanical and physical properties capable of fostering application in quality housing

Risk factors for mortality and effect of correct fluid prescription in children with diarrhoea and dehydration without severe acute malnutrition admitted to Kenyan hospitals: an observational, association study

Background Diarrhoea causes many deaths in children younger than 5 years and identification of risk factors for death is considered a global priority. The effectiveness of currently recommended fluid management for dehydration in routine settings has also not been examined. Methods For this observational, association study, we analysed prospective clinical data on admission, immediate treatment, and discharge of children age 1–59 months with diarrhoea and dehydration, which were routinely collected from 13 Kenyan hospitals. We analysed participants with full datasets using multivariable mixed-effects logistic regression to assess risk factors for in-hospital death and effect of correct rehydration on early mortality (within 2 days). Findings Between Oct 1, 2013, and Dec 1, 2016, 8562 children with diarrhoea and dehydration were admitted to hospital and eligible for inclusion in this analysis. Overall mortality was 9% (759 of 8562 participants) and case fatality was directly correlated with severity. Most children (7184 [84%] of 8562) with diarrhoea and dehydration had at least one additional diagnosis (comorbidity). Age of 12 months or younger (adjusted odds ratio [AOR] 1·71, 95% CI 1·42–2·06), female sex (1·41, 1·19–1·66), diarrhoea duration of more than 14 days (2·10, 1·42–3·12), abnormal respiratory signs (3·62, 2·95–4·44), abnormal circulatory signs (2·29, 1·89–2·77), pallor (2·15, 1·76–2·62), use of intravenous fluid (proxy for severity; 1·68, 1·41–2·00), and abnormal neurological signs (3·07, 2·54–3·70) were independently associated with inhospital mortality across hospitals. Signs of dehydration alone were not associated with in-hospital deaths (AOR 1·08, 0·87–1·35). Correct fluid prescription significantly reduced the risk of early mortality (within 2 days) in all subgroups: abnormal respiratory signs (AOR 1·23, 0·68–2·24), abnormal circulatory signs (0·95, 0·53–1·73), pallor (1·70, 0·95–3·02), dehydration signs only (1·50, 0·79–2·88), and abnormal neurological signs (0·86, 0·51–1·48). Interpretation Children at risk of in-hospital death are those with complex presentations rather than uncomplicated dehydration, and the prescription of recommended rehydration guidelines reduces risk of death. Strategies to optimise the delivery of recommended guidance should be accompanied by studies on the management of dehydration in children with comorbidities, the vulnerability of young girls, and the delivery of immediate care.</p

Appropriateness of clinical severity classification of new WHO childhood pneumonia guidance: a multi-hospital, retrospective, cohort study

Background Management of pneumonia in many low-income and middle-income countries is based on WHO guidelines that classify children according to clinical signs that define thresholds of risk. We aimed to establish whether some children categorised as eligible for outpatient treatment might have a risk of death warranting their treatment in hospital. Methods We did a retrospective cohort study of children aged 2–59 months admitted to one of 14 hospitals in Kenya with pneumonia between March 1, 2014, and Feb 29, 2016, before revised WHO pneumonia guidelines were adopted in the country. We modelled associations with inpatient mortality using logistic regression and calculated absolute risks of mortality for presenting clinical features among children who would, as part of revised WHO pneumonia guidelines, be eligible for outpatient treatment (non-severe pneumonia). Findings We assessed 16 162 children who were admitted to hospital in this period. 832 (5%) of 16 031 children died. Among groups defined according to new WHO guidelines, 321 (3%) of 11 788 patients with non-severe pneumonia died compared with 488 (14%) of 3434 patients with severe pneumonia. Three characteristics were strongly associated with death of children retrospectively classified as having non-severe pneumonia: severe pallor (adjusted risk ratio 5·9, 95% CI 5·1–6·8), mild to moderate pallor (3·4, 3·0–3·8), and weight-for-age Z score (WAZ) less than −3 SD (3·8, 3·4–4·3). Additional factors that were independently associated with death were: WAZ less than −2 to −3 SD, age younger than 12 months, lower chest wall indrawing, respiratory rate of 70 breaths per min or more, female sex, admission to hospital in a malaria endemic region, moderate dehydration, and an axillary temperature of 39°C or more. Interpretation In settings of high mortality, WAZ less than −3 SD or any degree of pallor among children with non-severe pneumonia was associated with a clinically important risk of death. Our data suggest that admission to hospital should not be denied to children with these signs and we urge clinicians to consider these risk factors in addition to WHO criteria in their decision making. Funding Wellcome Trust