Evaluating Different Dimensions of Programme Effectiveness for Private Medicine Retailer Malaria Control Interventions in Kenya

BACKGROUND: Private medicine retailers (PMRs) are key partners in the home management of fevers in many settings. Current evidence on effectiveness for PMR interventions at scale is limited. This study presents evaluation findings of two different programs implemented at moderate scale targeting PMRs for malaria control in the Kisii and Kwale districts of Kenya. Key components of this evaluation were measurement of program performance, including coverage, PMR knowledge, practices, and utilization based on spatial analysis. METHODOLOGY/PRINCIPAL FINDINGS: The study utilized mixed quantitative methods including retail audits and surrogate client surveys based on post-intervention cross-sectional surveys in intervention and control areas and mapping of intervention outlets. There was a large and significant impact on PMR knowledge and practices of the program in Kisii, with 60.5% of trained PMRs selling amodiaquine medicines in adequate doses compared to 2.8% of untrained ones (OR; 53.5: 95% CI 6.7, 428.3), a program coverage of 69.7% targeted outlets, and a potential utilization of about 30,000 children under five. The evaluation in Kwale also indicates a significant impact with 18.8% and 2.3% intervention and control PMRs selling amodiaquine with correct advice, respectively (OR; 9.4: 95% CI 1.1, 83.7), a program coverage of 25.3% targeted outlets, and a potential utilization of about 48,000 children under five. A provisional benchmark of 7.5 km was a reasonable threshold distance for households to access PMR services. CONCLUSIONS/SIGNIFICANCE: This evaluation show that PMR interventions operationalized in the district level settings are likely to impact PMR knowledge and practices and lead to increased coverage of appropriate treatment to target populations. There is value of evaluating different dimensions of public health programs, including quality, spatial access, and implementation practice. This approach strengthens the potential contribution of pragmatic study designs to evaluating public health programs in the real world

Factors influencing implementation of the Ministry of Health-led private medicine retailer programmes on malaria in Kenya

<p>Abstract</p> <p>Background</p> <p>Kenya has experienced a number of retail sector initiatives aimed at improving access to antimalarial medicines. This study explored stakeholders' perceptions of the role of private medicine retailers (PMRs), the value and feasibility of programme goals, perceived programme impact, factors influencing implementation and recommendations in three districts of Kenya.</p> <p>Methods</p> <p>This study was part of a larger evaluation of PMR programmes, including quantitative and qualitative components. The qualitative research was conducted to assess implementation processes and actors' experiences in the programmes, through focus group discussions with trained PMRs and mothers of children under five years, and in-depth interviews with programme managers, trainers and co-trainers.</p> <p>Results</p> <p>PMRs were perceived to provide rapid cheap treatment for non-serious conditions and used as a deliberate and continuously evaluated choice between different treatment sources. All stakeholders supported programme goals and most PMRs described increased customer satisfaction, more rational purchasing of medicine stock and increased medicine sales after participation. Factors undermining programme implementation included a lack of MoH resources to train and monitor large numbers of PMRs, the relative instability of outlets, medicines stocked and retail personnel, the large number of proprietary brands and financial challenges to retailers in stocking antimalarial medicines, and their customers in buying them. Unambiguous national support and a broad range of strategies are important to strengthen the feasibility of change in OTC antimalarial use.</p> <p>Conclusions</p> <p>Understanding the context and implementation processes of PMR programmes and the perspectives of key actors are critical to identifying measures to support their effective implementation. Financial barriers underlie many described challenges, with important implications for policies on subsidies in this sector. In spite of barriers to implementation, increased exposure to programme activities promoted trust and improved relationships between PMRs and their clients and trainers, strengthening feasibility of such interventions. Public information can strengthen PMR training programmes by engaging local communities and may facilitate performance monitoring of PMRs by their clients.</p

Methods used in prevalence studies of disrespect and abuse during facility based childbirth: lessons learned

Background: Several recent studies have attempted to measure the prevalence of disrespect and abuse (D&A) of women during childbirth in health facilities. Variations in reported prevalence may be associated with differences in study instruments and data collection methods. This systematic review and comparative analysis of methods aims to aggregate and present lessons learned from published studies that quantified the prevalence of Disrespect and Abuse (D&A) during childbirth. Methods: We conducted a systematic review of the literature in accordance with PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Five papers met criteria and were included for analysis. We developed an analytical framework depicting the basic elements of epidemiological methodology in prevalence studies and a table of common types of systematic error associated with each of them. We performed a head-to-head comparison of study methods for all five papers. Using these tools, an independent reviewer provided an analysis of the potential for systematic error in the reported prevalence estimates. Results: Sampling techniques, eligibility criteria, categories of D&A selected for study, operational definitions of D&A, summary measures of D&A, and the mode, timing, and setting of data collection all varied in the five studies included in the review. These variations present opportunities for the introduction of biases – in particular selection, courtesy, and recall bias – and challenge the ability to draw comparisons across the studies’ results. Conclusion: Our review underscores the need for caution in interpreting or comparing previously reported prevalence estimates of D&A during facility-based childbirth. The lack of standardized definitions, instruments, and study methods used to date in studies designed to quantify D&A in childbirth facilities introduced the potential for systematic error in reported prevalence estimates, and affected their generalizability and comparability. Chief among the lessons to emerge from comparing methods for measuring the prevalence of D&A is recognition of the tension between seeking prevalence measures that are reliable and generalizable, and attempting to avoid loss of validity in the context where the issue is being studied. Electronic supplementary material The online version of this article (10.1186/s12978-017-0389-z) contains supplementary material, which is available to authorized users

An assessment of opportunities and challenges for public sector involvement in the maternal health voucher program in Uganda

This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Background: Continued inequities in coverage, low quality of care, and high out-of-pocket expenses for health services threaten attainment of Millennium Development Goals 4 and 5 in many sub-Saharan African countries. Existing health systems largely rely on input-based supply mechanisms that have a poor track record meeting the reproductive health needs of low-income and underserved segments of national populations. As a result, there is increased interest in and experimentation with results-based mechanisms like supply-side performance incentives to providers and demand-side vouchers that place purchasing power in the hands of low-income consumers to improve uptake of facility services and reduce the burden of out-of-pocket expenditures. This paper describes a reproductive health voucher program that contracts private facilities in Uganda and explores the policy and implementation issues associated with expansion of the program to include public sector facilities. Methods: Data presented here describes the results of interviews of six district health officers and four health facility managers purposefully selected from seven districts with the voucher program in southwestern Uganda. Interviews were transcribed and organized thematically, barriers to seeking RH care were identified, and how to address the barriers in a context where voucher coverage is incomplete as well as opportunities and challenges for expanding the program by involving public sector facilities were investigated. Results: The findings show that access to sexual and reproductive health services in southwestern Uganda is constrained by both facility and individual level factors which can be addressed by inclusion of the public facilities in the program. This will widen the geographical reach of facilities for potential clients, effectively addressing distance related barriers to access of health care services. Further, intensifying ongoing health education, continuous monitoring and evaluation, and integrating the voucher program with other services is likely to address some of the barriers. The public sector facilities were also seen as being well positioned to provide voucher services because of their countrywide reach, enhanced infrastructure, and referral networks. The voucher program also has the potential to address public sector constraints such as understaffing and supply shortages.Conclusions: Accrediting public facilities has the potential to increase voucher program coverage by reaching a wider pool of poor mothers, shortening distance to service, strengthening linkages between public and private sectors through public-private partnerships and referral systems as well as ensuring the awareness and buy-in of policy makers, which is crucial for mobilization of resources to support the sustainability of the programs. Specifically, identifying policy champions and consulting with key policy sectors is key to the successful inclusion of the public sector into the voucher program

Reviewing the literature on access to prompt and effective malaria treatment in Kenya: implications for meeting the Abuja targets

<p>Abstract</p> <p>Background</p> <p>Effective case management is central to reducing malaria mortality and morbidity worldwide, but only a minority of those affected by malaria, have access to prompt effective treatment.</p> <p>In Kenya, the Division of Malaria Control is committed to ensuring that 80 percent of childhood fevers are treated with effective anti-malarial medicines within 24 hours of fever onset, but this target is largely unmet. This review aimed to document evidence on access to effective malaria treatment in Kenya, identify factors that influence access, and make recommendations on how to improve prompt access to effective malaria treatment. Since treatment-seeking patterns for malaria are similar in many settings in sub-Saharan Africa, the findings presented in this review have important lessons for other malaria endemic countries.</p> <p>Methods</p> <p>Internet searches were conducted in PUBMED (MEDLINE) and HINARI databases using specific search terms and strategies. Grey literature was obtained by soliciting reports from individual researchers working in the treatment-seeking field, from websites of major organizations involved in malaria control and from international reports.</p> <p>Results</p> <p>The review indicated that malaria treatment-seeking occurs mostly in the informal sector; that most fevers are treated, but treatment is often ineffective. Irrational drug use was identified as a problem in most studies, but determinants of this behaviour were not documented. Availability of non-recommended medicines over-the-counter and the presence of substandard anti-malarials in the market are well documented. Demand side determinants of access include perception of illness causes, severity and timing of treatment, perceptions of treatment efficacy, simplicity of regimens and ability to pay. Supply side determinants include distance to health facilities, availability of medicines, prescribing and dispensing practices and quality of medicines. Policy level factors are around the complexity and unclear messages regarding drug policy changes.</p> <p>Conclusion</p> <p>Kenya, like many other African countries, is still far from achieving the Abuja targets. The government, with support from donors, should invest adequately in mechanisms that promote access to effective treatment. Such approaches should focus on factors influencing multiple dimensions of access and will require the cooperation of all stakeholders working in malaria control.</p

“We are their eyes and ears here on the ground, yet they do not appreciate us”—Factors influencing the performance of Kenyan community health volunteers working in urban informal settlements

This study explored factors that influence CHV performance in urban informal settlements (UIS) within Nairobi Kenya and ways in which CHVs can be supported to enhance their wellbeing and strengthen community strategies. The study was undertaken in two UIS within Nairobi County. Thirteen focus group discussions and three key informant interviews were conducted with a range of respondents. Various topics covering the design of the Community Health Strategy (CHS) and broader contextual factors that affect CHVs’ performance, were discussed and data analysed using a framework analysis approach. The key programme design factors identified as influencing the performance of CHVs working in UIS included: CHV recruitment; training; availability of supplies and resources; and remuneration of CHVs. Health system factors that influenced CHVs performance included: nature of relationship between healthcare workers at local referral facilities and community members; availability of services and perceived corruption at referral facilities; and CHV referral outside of the local health facility. Whereas the broader contextual factors that affected CHV performance included: demand for material or financial support; perceived corruption in community programmes; and neighbourhood insecurity. These findings suggest that CHVs working in UIS in Kenya face a myriad of challenges that impact their wellbeing and performance. Therefore, to enhance CHVs’ well-being and improve their performance, the following should be considered: adequate and timely remuneration for CHVs, appropriate holistic training, adequate supportive supervision, and ensuring a satisfactory supply of resources and supplies. Additionally, at the facility level, healthcare workers should be trained on appropriate and respectful relations with both the community and the CHVs, clarity of roles and scope of work, ensure availability of services, and safeguard against corrupt practices in public health facilities. Lastly, there’s a need for improved and adequate security measures at the community level, to ensure safety of CHVs as they undertake their roles

Maps of study sites showing population distribution, retail outlets, health facilities and transport networks.

<p>The first map shows projected population densities for 2006 in each enumeration area (EA). The second map combines retail outlets, health facilities and transport networks.</p