Aggregate cost implications of selected Cost-Drivers \ud in the Tanzanian Health Sector\ud

\ud Health is an important aspect of life of which one of its determinants is healthcare which is consumed in order to restore back deteriorated health to optimal pre-illness levels. The consumption of healthcare however has cost implications and accounts for a large share of resources directed towards the health sector. In health sector financing, it is vital to identify major cost components and create awareness about the costs of decisions. It is thus vital to identify factors that can cause changes in the cost of identified activities. A number of costly programs have been initiated and some others are on the horizon. In order to create awareness about the financial consequences of these decisions and to draw attention to the financing needs of the health sector, it is considered necessary to analyze the major health sector programs and initiatives with regard to the changes in costs brought about by new strategies, guidelines and interventions (including the adoption of new technologies), and aggregate these costs. The main objective of this study was to identify cost-driving decisions in the health sector. The study methodology comprised of three independent but complementary methodologies and activities: (a) Desk review of literature and documents; (b) Interviews with officials from MOHSW, programs and agencies involved in setting and promoting standards at international level; (c) collection of primary data/information and subsequent analysis of the same. The study reviewed 11 plans, including summary plans like the Health Sector Strategic Plan III and the Primary Health Services Development Program 2007 -2017 and national disease control programme plans/strategies. However, not all of cost-driving decisions in these plans could be integrated into the analysis because the plans are undergoing reprogramming, as the previous cost estimates are regarded not to be realistic relative to achieving plan objectives. In addition the costs of some decisions in some plans/strategies HRH, infrastructure, health care financing strategy, mhealth, etc. are not established or are in the process of being costed or reviewed. It should also be noted that the consultants did not assess all plans/strategies and their associated costs as to their plausibility. This was neither task of the consultants, nor would the time allocated to the study have allowed such an in-depth review. The study reviewed a total of 11 multi-year plans/strategies and found four plans to be affected by costs of decisions. Such decisions are: the adaption of WHO recommendations on Anti-retroviral Treatment eligibility criteria; re-treatment of conventional nets; indoor residual spraying; sustaining availability of long lasting insecticide treated nets (LLINs); provision of delivery kits to pregnant women in public health facilities, and the potential future introduction of a malaria vaccine, human papilloma virus and pneumococcal vaccines, which affect the Health Sector HIV and AIDS Strategic Plan II (HSHSP II) 2008 – 2012, the Malaria Mid-Term Strategic Plan 2008 – 2013 (NMCP), the National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008 – 2015 (the Road Map), and the Expanded Program on Immunization 2010 - 2015 Comprehensive Multi Year Plan (EPI), respectively. The study found that these decisions have a significant cost implication to a tune of US$706,688,405 over a five year period 2011- 2015. The initially estimated costs of programs that are currently being updated (HSHSP II, EPI, NMCP and the Road Map) is US$ 2,297,009,378 exclusive of the identified cost drivers. The estimated cost of decisions is about 8 % of the total costs for health sector in Tanzania (HSSP III estimate) and about 3.3% of the 2009 GDP and added nominal per capita health spending/cost of US$17.3 (2009 population estimate) for five year period (annual per capita cost of US$ 3.46). This expenditure will definitely boost per capita health spending (US$13.45 in 2008/9). However, concerted revenue effort is needed if we are to hit HSSP III target of US$ 26.6 in 2014/15. The National Strategy for Non-communicable Diseases 2009 – 2015 did not include estimates, while most parts of the National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008 – 2015 are undergoing reprogramming, as the previous cost estimates are regarded not to be realistic relative to achieving plan objectives. The rest of the programs are not significantly affected by cost of decisions. However, the estimated cost is likely to be higher owing to the fact that costs of some decisions in MMAM components such as HRH, infrastructure, health care financing strategy, mhealth, etc. are not established or are in the process of being costed or reviewed. Prevention and treatment of illness are the major strategies used to maintain or improve the health status of a population. Allocation of health resources are usually skewed towards treatment probably because addressing existing illnesses seem a present and clear danger than addressing potential illnesses which is what prevention is all about. Prevention and health promotion however lead to greater benefits than treatment in the long run in the sense that it reduces future demand for treatment than treatment alone does and has stronger merit good characteristics than treatment of illness. Health planning should thus intensify focus on prevention through promoting lifestyle and behaviour changes as well as intensifying prevention and health promotion at community level. Most health sector multi-year plans are characterized by heavy resource dependence on development partners. Such levels of dependence tend to compromise control over some decisions especially those supported by financiers. That is, recipients may be tempted to accept a full funded activity even if there is an ongoing similar activity which ends up creating parallel rather than complementary activities with cost implications. Thus, the financiers and recipients should undertake thorough analysis of potential decisions based on their cost implications (direct and indirect) as well as the time parameters, while avoiding decisions that spin off similar activities rather than complementing the existing ones. This can be facilitated by coordinated analysis from the MOHSW by keeping and monitoring comprehensive cost driver table enriched by inputs from all health sector programs and plans. Continuous reviews of the plans enhance the capacity of programs to adequately identify cost drivers and therefore enhance the planning process. However, reviews are not always undertaken on time and as regular as possible due to lack of resources or transfer of resources set aside for review process to implement other pressing components of the plan. MOHSW should make costing part of the plan a compulsory exercise for approval by the management and should not endorse plans which have not been adequately costed. MOHSW should also consider making reviews of multi-year plans a prerequisite for release of fund for subsequent implementation. Moreover, the reviews should integrate all stakeholders and involve technical people who are knowledgeable in costing and planning. The fact that most of the multi-year plans had indicative budgets, while others are not costed at all, warrants the conclusion that the basic knowledge in costing such as collaboration, parameter assumptions, time, manpower, and resources is lacking. Emphasis should thus be placed on developing and improving costing capacity in the programs as well as the MOHSW in terms of acquiring costing tools and exposure. The MOHSW should ensure that the priority activities of the strategies/plans are funded. This could be done through lobbying the government and other stakeholders for more resources. Protocols such as Abuja Declaration 2001, in which African governments committed themselves to scale up health budget to 15% of the annual budget, could be useful in this end. Also the government and local authorities through laws/bylaws could establish and commit specific sources of resources for the health sector. This should be pursued by keeping a close eye on the ratio of available resources to required resources which can indicate opportunities which development partners can be of help as well as providing an indication of the realism of planning. A review of the plans found the ratio of available resources to required resources to be 76 and 84 percent, respectively, for the Health Sector Strategic Plan III and the Expanded Program on Immunization 2010 – 2015 Comprehensive Multi Year Plan. The Malaria Medium Term Strategic Plan 2008-2013 on the other hand had the lowest ratio of available resources to required resources of 35 percent.\u

Challenges Affecting Performance of Supply Chain Systems in the Petroleum Industries in Kenya

The purpose of this study was to establish the challenges affecting performance of supply chain systems in the petroleum industries in Kenya. The study was used to exam several parameters that affected’ Supply chain performance in Kenya resulting to often oil shortages. This has been occasioned by globalization which was intensifying competition and increased the mobility of high skilled personnel yet oil companies depend on the staff for success and sustainability. Specifically, the objectives of the study was to establish whether how these factors; level of skills, information and communication technology has effect on supply chain systems, This is a conceptual paper and the methodology used is analytical data after collection from the sample size targeted by the researcher in which in depth literature review is done to highlight how companies can incorporate performance of supply chain tools in their supply chains systems. The study was conducted using a survey design. A census of all the registered 73 oil companies was conducted. Data was collected by use of instruments. This involved both structured and semi-structured questions.  Data was analyzed mainly by use of descriptive and inferential statistic such as mean and standard deviation. This was more than the generally recommended sample size of 100 cases for statistical data analysis (Kothari, 2011). Inferential statistics including correlation, multiple regressions enter method and multiple regressions (Stepwise) for moderation analysis. Qualitative and Quantitative data was put into categories based on themes that was aligned to thesis objectives and was integrated in the findings. Keywords? Supply chain systems, level of skills, information communication and technolog

The Effects of Financial Institutions Intervention on the Growth of Small Enterprises in Kenya: A Survey of Public Service Transporters in Kisii Municipality

The small enterprises (SEs) play an important role in the Kenyan Economy. According to the Economic Survey, the sector contributed over 50 percent of new jobs created in the year 2005. Despite their significance, past statistics indicate that three out of five businesses fail within the first few months of operation. Approximately 80% of Kenya enterprises are Small enterprises which are highly attractive to banks. There has not been clear understanding of the key drivers of small enterprises growth. Kisii town is a home of 20 financial institutions, all of which offer almost the same financial services to the small entrepreneurs within the Municipality and yet there is a mixture of growth and lack of it in small enterprises in the municipality. This project was to investigate the effects of the financial institutions intervention in growth of Small Enterprises in Kisii Municipality. The specific objectives were: To establish the role of credit provision on growth of Small enterprises in Kisii Municipality, to determine the adequacy of financial training offered by financial institutions in helping the small enterprises to grow, to determine the role of marketing information on growth of small enterprises in Kisii Municipality. From the sampling frame a representative sample of 90 respondents were obtained randomly and a survey was conducted on this sample using both structured and un-structured interview schedules. Data from the respondents was analyzed and translated into useful information using the statistical package for social sciences (SPSS) and the Minitab statistical software. Frequency distributions and multiple regression analysis were used to draw conclusions. Most of the businesses were more than a year in operation before the credit was granted. The study also established that most of the businesses obtained loans from banks. More than half of the sample had accessed credit from a bank. Second is micro credit financing institutions where the respondents reported to have got loans from SACCO, Chamas and friends and relatives also play a significant role in the provision of these services. The study revealed that interests could be expensive but manageable. The survey established that accessibility and availability of micro credit are positively related to financial performance of Small enterprises. The study concludes that accessibility to credit affects financial performance of Small enterprises positively. The easier it is to access credit, the higher the financial performance of the Small enterprises. However, access to credit is not that easier from the financial institutions considering the many requirements one has to meet before the credit is approved to the entrepreneur for use in the business. The study concludes that availability of credit positively affects financial performance of small and medium businesses. This is an indication that as credit becomes more available, the financial performance of business becomes better and hence a chance for business growth. Financial training was found to be playing a crucial role in growth of small enterprises, especially in assisting the businesses to repay back their loans in order to get more credit in future. The research further found out that the accessibility to marketing information and its availability to the entrepreneurs also affects the transporters in a positive way in their performance of the businesses.The study recommends that the government and financial institutions should make micro credit more accessible and available to enhance growth and development of Small enterprises through increased profitability as it was found that accessibility and availability of microcredit have positive impact on the performance of Small enterprises.The study also recommends that the government through it central bank should have financial policy that will help offer better interest rate that will enhances the accessibility of credit and enhance reduction of interest rates so as to uplift the financial performance of Small enterprises as it was found that high interest rates had a negative relationship with financial performance of Small enterprises.The study recommends further on financial training as it was found to be playing a crucial role in growth of small enterprises, especially in assisting the businesses to repay back their loans in order to get more credit in future. The researcher further recommends for the accessibility to marketing information and its availability to the entrepreneurs in order to positively assist the entrepreneurs in their day to day activities which was found to affect the financial performance of SMEs. The results of this study are expected to assist the county government and stakeholders to formulate and implement appropriate policies aimed at developing and empowering Small entrepreneurs. Keywords : Enterprise, Experience, Finance, Demand, Competition, Entrepreneu

Uptake and determinants of cervical cancer screening among health care workers in Aga Khan university hospital, Nairobi Kenya.

Background: The cancer burden has been rising globally. The reported incidence of cervical cancer is 13.1 / 100,000 globally and 40 / 100,000 in Kenya. Up to 88% of all cervical cancer deaths have been reported in lower to middle-income countries. In comparison, developed countries had up to two to four times lower rates of cervical cancer incidence and mortality. The burden of cancers attributable to carcinogenic infections has potentially modifiable risk factors, for which prevention tools already exist. There is a gap in the implementation of evidence-based interventions including primary prevention with the HPV vaccine and secondary prevention with screening and treatment of early precancerous lesions. Both structural and personal impediments to screening programs commonly encountered in sub-Saharan Africa include lack of availability, accessibility, affordability of health services, limited resources, lack of awareness, high HIV burden, poor health-seeking behavior, and psychological factors. The Kenyan government is rolling out cervical cancer screening programs, but the coverage is still low, mainly due to lack of awareness, knowledge, lack of services, and cost of screening, fear, ignorance, and stigma. Therefore, we decided to study the level of screening and determinants of screening, in a well-educated population with good medical coverage, health insurance, and availability of services, to understand the factors that play a role even in this population. In addition, we decided to explore the role of men in the prevention of cervical cancer. Traditionally men have not been involved in reproductive health, as it has always been considered as a woman’s domain. Policy development in family planning has engaged men in taking a proactive role and this has seen acceptability and increased uptake of family planning services, which could be modeled in other preventive and promotion programs of screening for cervical cancer. Methods: We performed a descriptive cross-sectional study recruiting from a population of 2246 healthcare staff offering direct or indirect health services in the Aga Khan University Hospital, Nairobi, Kenya. The study population was stratified into clinical, administrative, and support staff. The nonprobability sampling method was done proportionately to the size of the population to ensure equal representation. Using the prevalence calculation, 362 participants were invited and directly approached after adjusting from the finite population. Data were obtained using a validated semi-structured Cervical cancer Awareness Measure questionnaire (CAM tool). Which collected data including socio-demographics, screening practices and attitudes, advocacy, and knowledge on vaccination. The present study used the Chi-square test for data analysis and further explored the data for an independent variable using multivariate logistic regression. The perceived psychological barriers to health-seeking behavior seen in the study were discussed using the Health Belief Model for the identification of actions to achieve efficacy in the uptake of cervical cancer screening. Results: Out of the 362 invited staff, 352 agreed to participate in the study (97.2 % response rate), with 295 (83.8%) females and 57 (16.2%) males. Out of the 295 females, 183 (62%) (95% CI: 56.2% to 67.6%) had ever been screened for cervical cancer while 112 (38%) were never screened. Factors associated with cervical cancer screening included age above 30 years, parity, marital status, insurance cover, exposure or caring for a cervical cancer patient. On prevention of cervical cancer, 271 (77%) both males and females participants knew the correct age of vaccination, and 24 (8.1%) of the female participants had been vaccinated for cervical cancer. Only 36 (10.2%) of both females and males participants believed in the protective effects of the vaccine, 149(50.5%) of the female participants and 25(43%) of male participants did not believe that vaccination is protective against cervical cancer. On the uptake of routine screening among the 183 females who had ever been screened, 30 (16.4%) had three yearly screening results, with 153(83.6%) were either screened or awaiting due screening interval or not following the recommended interval for screening after the initial screening. Of the 112 females who had not screened for cervical cancer, 59 (52.7%) cited the test as invasive. Out of the 41 (13.9%) female participants who declined future screening opportunities, 68.3% cited psychological factors including fear of the procedure. Of the male participants 42 (63.7%) knew the status of screening of either their partner or close family member with only 9 (15.8%) correctly identified the recommended age of screening. Forty-four (77.2%) males were aware of the availability of cervical cancer vaccine though only 6(10.1%) thought that vaccination against cervical cancer was protective. Insurance cover was high in this population with 294 (83.5%), with a majority of 303 (86.1%) being aware of the cervical screening program availability. Health education was the primary source of current knowledge for 262 (74.4%), while only 103 (29.3%) relied on media as their source of cervical cancer knowledge. Women who had high knowledge of cervical cancer were twice as likely to be screened for cervical cancer as those with low knowledge of cervical cancer (AOR: 2.085; 95% CI: 1.212-3.631). Conclusions: The study illustrates a 62% screening rate in healthcare workers in a private tertiary hospital with minimal to no structural barriers to screening. Personal psychological barriers, including fear of the screening procedure, were the principal reasons for not screening or going for routine screening. In Aga Khan vii University Hospital, there is still an opportunity to increase the acceptability of the test by addressing the psychological fear of the procedure. This can be done by filling of surveys in each vist and counselling of the patients before the procedure. Innovative screening services can be assessed and offered as an alternative to the regular pap smear, so as to increase acceptability of conducting the screening procedure. Likewise, the structuring of education programs can be included in the policy to focus on cervical cancer, screening practices, and importance of vaccination. In addition, cues for action like media campaigns, training programs, and yearly message reminders for screening will aid in increasing cervical cancer screening rates. The findings of this study will be important to share with the governmental and non-governmental stakeholders focusing on cervical cancer screening barriers. The identified personal barriers together with the existing structural barriers need to be addressed in vulnerable populations to improve future cervical cancer screening rates in Kenya. Likewise, implementation of the existing study findings and evidence-based interventions can help achieve the goal of elimination of this preventable cancer

East Ends: race, place and community in the story of the emergence of Grime music

This thesis tells the story of the emergence of Grime music. Grime, as a music sub-culture has its origins in the Caribbean community of East London, at the turn of the twenty-first century and can be seen as a continuation of the lineage of Caribbean and Caribbean-British music genres that also takes in influences from other parts of the world. I will be describing the story of Grime from a particular angle: that which considers the racial prejudice, and cultural suppression faced by London’s black communities in the period before Grime’s emergence, as well as during it, and the effects of economic gentrification in the area. I will demonstrate that a combination of British racism and local gentrification were responsible for Grime being pushed out of its traditional communities. I will support this, despite a paucity of academic texts, by drawing on a vast wealth of online resources that followed Grime’s forced transition from the physical environment of East London to the digital world. I will also argue that this transition, though an unintentional effect of suppression, is the cause behind Grime’s rise to becoming a mainstream culture that now represents Britain’s wider working-class black and ethnic minority community while maintaining its street authenticity: its life-source and central ethos

The Interbank Market in Kenya: An Event-Based Stress Analysis Based on Treasury Bill Market

This paper seeks to explore nexus between the volatility in the Kenyan interbank market and Treasury bill market in the event of market distress arising from collapses of a lender. Three stress triggering events are defined; -the placement of Dubai Bank, Imperial Bank and Chase Bank placement under receivership. The inclusion of Treasury bill market is aimed to ascertaining whether then Central Bank’s intervention in the market to correct inefficiency in the interbank market upon the collapse of a lender is either proactive or reactive. The EGARCH and TGARCH were used to model the relationship. Key finding of the study is that 91-Day Treasury bill rate positively and significantly affects the interbank market rate with the effect doubling in the wake of bank collapse