Improving the Supply Chains for the Health Sector: What Role for Locally Manufactured and Imported Medicines and Medical Supplies in Kenya?

This Issue Paper presents some findings on research on supply within Kenya from local manufacturers to the health system. It compares the sourcing of local supplies and competing imports within the public, private and faith-based sectors of health care. Finally, it presents perceptions of Kenyan health sector actors at all levels on the extent to which improved local manufacturing supplies could help to increase access to essential medicines and medical supplies within Kenya. The evidence presented here was collected as part of a research project entitled Industrial Productivity and Health Sector Performance (www.iphsp.acts-net.org).This was a collaborative research project undertaken by the African Centre for Technology Studies (ACTS), Nairobi; REPOA, Dar es Salaam; and The Open University, UK. The project aims to identify opportunities for improved local industrial supply of medical products to strengthen Kenyan and Tanzanian health system performance

Local Supply Chains for Medicines and Medicinal Supplies in Kenya: Understanding the Challenges

This Working Paper presents some findings from a research project on Industrial Productivity and Health Sector Performance, collaborative research by the African Centre for Technology Studies (ACTS), Nairobi; REPOA, Dar es Salaam; and The Open University, UK. The project aimed to identify opportunities for improved local industrial supply of medical products to strengthen Kenyan and Tanzanian health system performance. This working paper briefly outlines project methods and key concepts. It then summarises findings from health sector research in four Kenyan districts on the supply chains for selected essential medicines and supplies to facilities in the public, private and faith-based sectors and to private shops. The paper analyses strengths and weaknesses of the public and private supply chains into the health sector, as seen by health facility and pharmacy staff

The Cancer Care Challenge in the Light of Pandemic Experience

This introductory chapter argues that tackling the escalating cancer crisis in Africa and India is essential for human wellbeing and inclusive health care, while having much to teach about how to build better local health security in low- and middle-income contexts. Global health security is built on the foundations of strong local health security. Local health security in turn relies on effective and innovative industrial supply chains to provide essential medicines, devices and other commodities at manageable prices, and effective industrial-health sector policy collaboration to ensure broad health benefit, lessons the pandemic has hammered home

Layered vulnerability and researchers’ responsibilities: learning from research involving Kenyan adolescents living with perinatal HIV infection

Background: Carefully planned research is critical to developing policies and interventions that counter physical, psychological and social challenges faced by young people living with HIV/AIDS, without increasing burdens. Such studies, however, must navigate a ‘vulnerability paradox’, since including potentially vulnerable groups also risks unintentionally worsening their situation. Through embedded social science research, linked to a cohort study involving Adolescents Living with HIV/AIDS (ALH) in Kenya, we develop an account of researchers’ responsibilities towards young people, incorporating concepts of vulnerability, resilience, and agency as ‘interacting layers’. Methods: Using a qualitative, iterative approach across three linked data collection phases including interviews, group discussions, observations and a participatory workshop, we explored stakeholders’ perspectives on vulner- ability and resilience of young people living with HIV/AIDS, in relation to home and community, school, health care and health research participation. A total of 62 policy, provider, research, and community-based stakeholders were involved, including 27 ALH participating in a longitudinal cohort study. Data analysis drew on a Framework Analysis approach; ethical analysis adapts Luna’s layered account of vulnerability. Results: ALH experienced forms of vulnerability and resilience in their daily lives in which socioeconomic context, institutional policies, organisational systems and interpersonal relations were key, interrelated influences. Anticipated and experienced forms of stigma and discrimination in schools, health clinics and communities were linked to actions undermining ART adherence, worsening physical and mental health, and poor educational outcomes, indicating cascading forms of vulnerability, resulting in worsened vulnerabilities. Positive inputs within and across sectors could build resilience, improve outcomes, and support positive research experiences. Conclusions: The most serious forms of vulnerability faced by ALH in the cohort study were related to structural, inter-sectoral influences, unrelated to study participation and underscored by constraints to their agency. Vulnerabili- ties, including cascading forms, were potentially responsive to policy-based and interpersonal actions. Stakeholder engagement supported cohort design and implementation, building privacy, stakeholder understanding, interper- sonal relations and ancillary care policies. Structural forms of vulnerability underscore researchers’ responsibilitie

First Africa non-communicable disease research conference 2017: sharing evidence and identifying research priorities

Non-communicable diseases (NCDs) prevalence is rising fastest in lower income settings, and with more devastating outcomes compared to High Income Countries (HICs). While evidence is consistent on the growing health and economic consequences of NCDs in sub-Saharan Africa (SSA), specific efforts aimed at addressing NCD prevention and control remain less than optimum and country level progress of implementing evidence backed cost-effective NCD prevention approaches such as tobacco taxation and restrictions on marketing of unhealthy food and drinks is slow. Similarly, increasing interest to employ multi-sectoral approaches (MSA) in NCD prevention and policy is impeded by scarce knowledge on the mechanisms of MSA application in NCD prevention, their coordination, and potential successes in SSA. In recognition of the above gaps in NCD programming and interventions in Africa, the East Africa NCD alliance (EANCDA) in partnership with the African Population and Health Research Center (APHRC) organized a three-day NCDs conference in Nairobi. The conference entitled “First Africa Non-Communicable Disease Research Conference 2017: Sharing Evidence and Identifying Research Priorities” drew more than one hundred fifty participants and researchers from several institutions in Kenya, South Africa, Nigeria, Cameroon, Uganda, Tanzania, Rwanda, Burundi, Malawi, Belgium, USA and Canada. The sections that follow provide detailed overview of the conference, its objectives, a summary of the proceedings and recommendations on the African NCD research agenda to address NCD prevention efforts in Africa

Access to Cancer Care: navigating the maze

This chapter analyses narratives from over 450 patients in Kenya and Tanzania, describing their cancer “pathways”, drawing also on views from carers and health workers. We characterise patients’ experiences as, too often, finding themselves in a “maze” after they first visit a health facility. Rather than a smooth clinical pathway from symptoms to diagnosis, patients had found themselves struggling to find money to move through a confusing health system maze, largely without maps or guides to aid their search for information, diagnosis and treatment. The chapter describes patterns of experience within the maze, and implications for access to care

Conclusion: Better Cancer Care and Greater Local Health Security: Lessons, Opportunities and Ways Forward

In pulling together the book’s analytical themes and practical lessons in the conclusion, this chapter emphasises as a core theme the scope for bringing together health, industrial development and innovation to build greater local health security, for cancer care, across the spectrum of health need and pandemic preparedness. The pandemic and our study of cancer care reinforced the importance of simultaneous co-resolution of challenges pertaining to health systems strengthening, development of broad industrial capabilities and improvements in planning, organisational, funding and institutional capabilities. This is critical for building agile and resilient local health security, a critical pre-condition for global health security

Access to Cancer Care in Kenya: Patients’, Survivors’, Caregivers’ and Health Providers’ Perspectives

Access to health care remains a complex notion with varying interpretations and no universally accepted definition. At least half of the world’s population lacks access to essential health services. The literature identifies “6As” dimensions of Access: Accessibility, Affordability, Availability, Adequacy /Appropriateness, Acceptability and Approachability. This paper employs these dimensions in documenting factors that were found to influence access to cancer care in Kenya. Health and Industry studies were conducted sequentially. The health part of the study reported in this working paper, employed a convergent parallel mixed methods study design which was undertaken in three counties of Meru, Nairobi and Mombasa. A total of 405 patients were interviewed in public sector health facilities, four focus group discussions with cancer survivors and 22 in-depth interviews with caregivers, health workers and policy makers held. Affordability of cancer services was enabled largely by cash payment with incremental use of National Hospital Insurance Fund (NHIF) from entry in health care up to the first treatment, but the high costs of cancer services were a major challenge. Payments for tests, treatment and indirect costs including transport and accommodation potentially impoverished many patients and their families as well as social networks . Facilities were financially supported by County Government funding, business and non-profit partners, and collaborations between health facilities to reduce indirect costs for the patients. Approachability was facilitated by community outreach services, local networks, awareness and knowledge promotion. However, better linkage between the community and health facility was required, especially for screening services. Availability: 30% of survey participants indicated that something they needed at the health facility was unavailable. The missing items included: medication, tests, treatment therapies, pain relief and essential commodities. Qualitative findings identified additional requirements including oncology staff and equipment. Patients also considered aspects of care that were unacceptable, and mentioned fear, stigma, cultural influences, religious and alternative beliefs. Nonetheless, having information and support from family, friends and other patient’s facilitated acceptability of cancer services. Accessibility in terms of distance and time to reach cancer care services located at county or national referral facilities was reported as a challenge for many. Communication, including lack of clarity, mis-diagnosis and non-disclosure of relevant information emerged as an appropriateness concern. It is important to note that the six access dimensions interact and therefore, may not be addressed separately. When these aspects of access to cancer care are facilitated, then access can be improved. Hence, a holistic health system approach to access is desirable, while emphasis should be put on enhancing diagnostic capabilities at lower levels of care in line with the objective of Universal Health Coverage. Mutually supportive interventions to strengthen access can include wider insurance coverage, extended staffing and improved information. When challenges to any of the access dimensions remain, then access to cancer care is undermined

Rethinking health sector procurement as developmental linkages in East Africa

Health care forms a large economic sector in all countries, and procurement of medicines and other essential commodities necessarily creates economic linkages between a country's health sector and local and international industrial development. These procurement processes may be positive or negative in their effects on populations' access to appropriate treatment and on local industrial development, yet procurement in low and middle income countries (LMICs) remains under-studied: generally analysed, when addressed at all, as a public sector technical and organisational challenge rather than a social and economic element of health system governance shaping its links to the wider economy. This article uses fieldwork in Tanzania and Kenya in 2012–15 to analyse procurement of essential medicines and supplies as a governance process for the health system and its industrial links, drawing on aspects of global value chain theory. We describe procurement work processes as experienced by front line staff in public, faith-based and private sectors, linking these experiences to wholesale funding sources and purchasing practices, and examining their implications for medicines access and for local industrial development within these East African countries. We show that in a context of poor access to reliable medicines, extensive reliance on private medicines purchase, and increasing globalisation of procurement systems, domestic linkages between health and industrial sectors have been weakened, especially in Tanzania. We argue in consequence for a more developmental perspective on health sector procurement design, including closer policy attention to strengthening vertical and horizontal relational working within local health-industry value chains, in the interests of both wider access to treatment and improved industrial development in Africa

Applying a gender lens to understand pathways through care for acutely ill young children in Kenyan urban informal settlements

Background: In many African settings, gender strongly influences household treatment-seeking and decision-making for childhood illnesses. While mothers are often the primary engagers with health facilities, their independence in illness-related decisions is shaped by various factors. Drawing on a gender lens, we explored treatment-seeking pathways pre- and post-hospital admission for acutely ill young children living in low income settlements in Nairobi, Kenya; and the gendered impact of child illness both at the household and health system level. Methods: Household members of 22 children admitted to a public hospital were interviewed in their homes several times post hospital discharge. In-depth interviews covered the child's household situation, health and illness; and the family's treatment-seeking choices and experiences. Children were selected from an observational cohort established by the Childhood Acute Illness and Nutrition (CHAIN) Network. Results: Treatment-seeking pathways were often long and complex, with mothers playing the key role in caring for their children and in treatment decision-making. Facing many anxieties and dilemmas, mothers often consulted with significant influencers - primarily women - particularly where illnesses were prolonged or complex. In contrast to observations in rural African contexts, fathers were less prominent as influencers than (often female) neighbours, grandparents and other relatives. Mothers were sometimes blamed for their child's condition at home and at health facilities. Children's illness episode and associated treatment-seeking had significant gendered socio-economic consequences for households, including through mothers having to take substantial time off work, reduce their working hours and income, or even losing their jobs. Conclusion: Women in urban low-income settings are disproportionately impacted by acute child illness and the related treatment-seeking and recovery process. The range of interventions needed to support mothers as they navigate their way through children's illnesses and recovery include: deliberate engagement of men in child health to counteract the dominant perception of child health and care as a 'female-domain'; targeted economic strategies such as cash transfers to safeguard the most vulnerable women and households, combined with more robust labour policies to protect affected women; as well as implementing strategies at the health system level to improve interactions between health workers and community members.The primary author (KM) was funded through the DELTAS Africa Initiative [DEL-15-003]. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust [107769/Z/10/Z] and the UK government. This work was supported by the Bill and Melinda Gates Foundation awarded to the CHAIN Network (grant: OPP1131320)