Economic evaluation of a conditional cash transfer to retain women in the continuum of care during pregnancy, birth and the postnatal period in Kenya

There is limited evidence on the cost and cost-effectiveness of cash transfer programmes to improve maternal and child health in Kenya and other sub-Saharan African countries. This article presents the economic evaluation results of the Afya trial, assessing the costs, cost-effectiveness and equity impact of a demand-side financing intervention that promotes utilisation of maternal health services in rural Kenya. The cost of implementing the Afya intervention was estimated from a provider perspective. Cost data were collected prospectively from all implementing and non-implementing partners, and from health service providers. Cost-efficiency was analysed using cost-transfer ratios and cost per mother enrolled into the intervention. Cost-effectiveness was assessed as cost per additional eligible antenatal care visit as a result of the intervention, when compared with standard care. The equity impact of the intervention was also assessed using a multidimensional poverty index (MPI). Programme cost per mother enrolled was International (INT)$313 of which INT$ 92 consisted of direct transfer payments, suggesting a cost transfer ratio of 2.4. Direct healthcare utilisation costs reflected a small proportion of total provider costs, amounting to INT$21,756. The total provider cost of the Afya intervention was INT$808,942. The provider cost per additional eligible ANC visit was INT$1,035. This is substantially higher than estimated annual health expenditure per capita at the county level of$INT61. MPI estimates suggest around 27.4% of participant households were multidimensionally poor. MPI quintiles did not significantly modify the intervention effect, suggesting the impact of the intervention did not differ by socioeconomic status. Based on the available evidence, it is not possible to conclude whether the Afya intervention was cost-effective. A simple comparison with current health expenditure in Siaya county suggests that the intervention as implemented is likely to be unaffordable. Consideration needs to be given to strengthening the supply-side of the cash transfer intervention before replication or uptake at scale

Menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls in western Kenya: a cluster-randomised controlled trial.

Background: High rates of sexual and reproductive health (SRH) harms and interrupted schooling are global challenges for adolescent girls, requiring effective interventions. We assessed the impact of menstrual cups (MCs) or cash transfers conditioned on school attendance (CCTs), or both, against SRH and schooling outcomes in western Kenya. Methods: In this cluster-randomised Cups or Cash for Girls (CCG) trial, adolescent girls in Forms two and three at 96 secondary schools in Siaya County (western Kenya) were randomised to receive either CCT, MC, combined CCT and MC, or control (1:1:1:1) for an average of 30 months. The CCT intervention comprised 1500KES (US$15 in 2016) via a cash card each school trimester. All four treatment groups received puberty and hygiene training at enrolment. Assenting girls with parent or guardian consent who were post-menarche, not pregnant, area residents, not boarding, and had no disabilities precluding participation were eligible. Socio-behavioural risk factors and incidence of HIV and herpes simplex virus type 2 (HSV-2) were measured annually. School retainment and adverse events were monitored throughout. The primary outcome comprised a composite of incident HIV, HSV-2 and/or all-cause school dropout by school exit examination. The primary analysis was by intention-to-treat (ITT) using multi-level generalised linear models, controlling for a priori selected baseline covariates. The trial is registered with ClinicalTrials.gov, NCT03051789. Findings: Between February 28, 2017 and June 30, 2021, 4137 girls (median age 17·1 [interquartile range (IQR): 16·3-18·0]) were enrolled and followed annually until completion of secondary school (median 2·5 years [IQR: 2·4-2·7]); 4106 (99·3%) contributed to the ITT analysis. No differences in the primary composite outcome between intervention and control groups were seen (MC: 18·2%, CCT: 22·1%, combined: 22·1%, control: 19·6%; adjusted risk ratio [aRR]: 0·97, 95% confidence interval 0·76-1·24; 1·14, 0·90-1·45; and 1·13, 0·90-1·43, respectively). Incident HSV-2 occurred in 8·6%, 13·3%, 14·8%, and 12% of the MC, CCT, combined and control groups, respectively (MC: RR:0·67, 0·47-0·95, p=0·027; aRR: 0·71, 0·50-1·01, p=0·057; CCT: aRR:1·02, 0·73-1·41, p=0·92; combined aRR:1·16, 0·85-2·58, p=0·36). Incident HIV was low (MC: 1·2%, CCT: 1·5%, combined: 1·0%, and control: 1·4%; aRR: 0·88, 0·38-2·05, p=0·77, aRR: 1·16, 0·51-2·62, p=0·72, aRR: 0·80, 0·33-1·94, p=0·62, respectively). No intervention decreased school dropout (MC: 11·2%, CCT: 12·4%, combined: 10·9%, control: 10·5%; aRR: 1·16, 0·86-1·57; 1·23, 0·91-1·65; and 1·06, 0·78-1·44, respectively). No related serious adverse events were seen. Interpretation: MCs, CCTs, or both, did not protect schoolgirls against a composite of deleterious harms. MCs appear protective against HSV-2. Studies of longer follow-up duration with objective measures of health impact are needed in this population

Comparing Sanitation Delivery Modalities in Urban Informal Settlement Schools: A Randomized Trial in Nairobi, Kenya

The provision of safely managed sanitation in informal settlements is a challenge, especially in schools that require durable, clean, sex-segregated facilities for a large number of children. In informal settlements in Nairobi, school sanitation facilities demand considerable capital costs, yet are prone to breakage and often unhygienic. The private sector may be able to provide quality facilities and services to schools at lower costs as an alternative to the sanitation that is traditionally provided by the government. We conducted a randomized trial comparing private sector service delivery (PSSD) of urine-diverting dry latrines with routine waste collection and maintenance and government standard delivery (GSD) of cistern-flush toilets or ventilated improved pit latrines. The primary outcomes were facility maintenance, use, exposure to fecal contamination, and cost. Schools were followed for one school year. There were few differences in maintenance and pathogen exposure between PSSD and GSD toilets. Use of the PSSD toilets was 128% higher than GSD toilets, as measured with electronic motion detectors. The initial cost of private sector service delivery was USD 2053 (KES 210,000) per school, which was lower than the average cost of rehabilitating the government standard flush-type toilets (USD 9306 (KES 922,638)) and constructing new facilities (USD 114,889 (KES 1,169,668)). The private sector delivery of dry sanitation provided a feasible alternative to the delivery of sewage sanitation in Nairobi informal settlements and might elsewhere in sub-Saharan Africa

The Life-Cycle Costs of School Water, Sanitation and Hygiene Access in Kenyan Primary Schools

Water, Sanitation and Hygiene (WASH) programs in schools can increase the health, dignity and comfort of students and teachers. Understanding the costs of WASH facilities and services in schools is one essential piece for policy makers to utilize when budgeting for schools and helping to make WASH programs more sustainable. In this study we collected data from NGO and government offices, local hardware shops and 89 rural primary schools across three Kenyan counties. Current expenditures on WASH, from school and external (NGO, government, parent) sources, averaged 1.83 USD per student per year. After reviewing current expenditures, estimated costs of operations and maintenance for bringing schools up to basic WASH standards, were calculated to be 3.03 USD per student per year. This includes recurrent costs, but not the cost of installing or setting up WASH infrastructure, which was 18,916 USD per school, for a school of 400 students (4.92 USD per student, per year). These findings demonstrate the need for increases in allocations to schools in Kenya, and stricter guidance on how money should be spent on WASH inputs to enable all schools to provide basic WASH for all students