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To better understand the wide variation of performance among county health systems in Kenya, this study investigated their performance determinants. We selected five counties with varied performance and examined their performance across five domains containing 10 thematic areas. We conducted a stakeholder analysis, consisting of focus group discussions and key informant interviews, and administered a quantitative survey to quantify the magnitude of inefficiency. The study found that a shortage of funding was one of the most common complaints from counties, leading to inefficiency in the health system. Another major reason for inefficiencies was the delay in disbursing funding to health facilities, which affected the procurement of medical supplies and commodities essential for delivering healthcare to the population. In addition, lack of autonomy in procuring commodities and equipment was repeatedly mentioned as a barrier to delivering quality health services. Other reported common concerns contributing to the performance of county health systems were the lack of lab tests and equipment, low willingness to join health insurance, rigid procurement policies and lengthy procurement process, lack of motivation and incentives for service delivery, and poor economic status. Despite the common concerns among the five counties, they differed in some schematic areas, such as the county’s commitment to health and community mobilization. In summary, this study suggests various factors that determine county health system performance. Given the multifaceted nature of inefficiency drivers, it is necessary to adopt a holistic approach to address the causes of inefficiencies and improve the county health systems

Sub-Saharan Africa has fewer medical workers per capita than any region of the world, and that shortage has been highlighted consistently as a critical constraint to improving health outcomes in the region. This paper draws on newly available, systematic, comparable data from ten countries in the region to explore the dimensions of this shortage. We find wide variation in human resources performance metrics, both within and across countries. Many facilities are barely staffed, and effective staffing levels fall further when adjusted for absenteeism. However, caseloads—while also varying widely within and across countries—are also low in many settings, suggesting that even within countries, deployment rather than shortages, together with barriers to demand, may be the principal challenges. Beyond raw numbers, we observe significant proportions of health workers with very low levels of clinical knowledge on standard maternal and child health conditions. This work demonstrates that countries may need to invest broadly in health workforce deployment, improvements in capacity and performance of the health workforce, and on addressing demand constraints, rather than focusing narrowly on increases in staffing numbers.Key messagesThis study analyzed health worker surveys from ten countries in Sub-Saharan Africa for a deeper understanding of human resource challenges.Average staffing across facilities is far below the stated staffing norms for each country.Half of health centers and health posts have one or fewer clinical staff assigned to them.Staffing is even lower when adjusted for absence, which is highest in small facilities and public facilities.Massive within-country variation in caseload suggests that staffing problems may be solved in part by reallocation of clinical staff.Health workers lack basic clinical competencies, caseloads are imbalanced, and there is substantial absence of workers from health facilities.

ObjectiveAssess the quality of healthcare across African countries based on health providers’ clinical knowledge, their clinic attendance and drug availability, with a focus on seven conditions accounting for a large share of child and maternal mortality in sub-Saharan Africa: malaria, tuberculosis, diarrhoea, pneumonia, diabetes, neonatal asphyxia and postpartum haemorrhage.MethodsWith nationally representative, cross-sectional data from ten countries in sub-Saharan Africa, collected using clinical vignettes (to assess provider knowledge), unannounced visits (to assess provider absenteeism) and visual inspections of facilities (to assess availability of drugs and equipment), we assess whether health providers are available and have sufficient knowledge and means to diagnose and treat patients suffering from common conditions amenable to primary healthcare. We draw on data from 8061 primary and secondary care facilities in Kenya, Madagascar, Mozambique, Nigeria, Niger, Senegal, Sierra Leone, Tanzania, Togo and Uganda, and 22 746 health workers including doctors, clinical officers, nurses and community health workers. Facilities were selected using a multistage cluster-sampling design to ensure data were representative of rural and urban areas, private and public facilities, and of different facility types. These data were gathered under the Service Delivery Indicators programme.ResultsAcross all conditions and countries, healthcare providers were able to correctly diagnose 64% (95% CI 62% to 65%) of the clinical vignette cases, and in 45% (95% CI 43% to 46%) of the cases, the treatment plan was aligned with the correct diagnosis. For diarrhoea and pneumonia, two common causes of under-5 deaths, 27% (95% CI 25% to 29%) of the providers correctly diagnosed and prescribed the appropriate treatment for both conditions. On average, 70% of health workers were present in the facilities to provide care during facility hours when those workers are scheduled to be on duty. Taken together, we estimate that the likelihood that a facility has at least one staff present with competency and key inputs required to provide child, neonatal and maternity care that meets minimum quality standards is 14%. On average, poor clinical knowledge is a greater constraint in care readiness than drug availability or health workers’ absenteeism in the 10 countries. However, we document substantial heterogeneity across countries in the extent to which drug availability and absenteeism matter quantitatively.ConclusionOur findings highlight the need to boost the knowledge of healthcare workers to achieve greater care readiness. Training programmes have shown mixed results, so systems may need to adopt a combination of competency-based preservice and in-service training for healthcare providers (with evaluation to ensure the effectiveness of the training), and hiring practices that ensure the most prepared workers enter the systems. We conclude that in settings where clinical knowledge is poor, improving drug availability or reducing health workers’ absenteeism would only modestly increase the average care readiness that meets minimum quality standards.

The Drosophila melanogaster DmATPCL gene encodes for the human ATP Citrate Lyase (ACL) ortholog, a metabolic enzyme that from citrate generates glucose-derived Acetyl-CoA, which fuels central biochemical reactions such as the synthesis of fatty acids, cholesterol and acetylcholine, and the acetylation of proteins and histones. We had previously reported that, although loss of Drosophila ATPCL reduced levels of Acetyl-CoA, unlike its human counterpart, it does not affect global histone acetylation and gene expression, suggesting that its role in histone acetylation is either partially redundant in Drosophila or compensated by alternative pathways. Here, we describe that depletion of DmATPCL affects spindle organization, cytokinesis, and fusome assembly during male meiosis, revealing an unanticipated role for DmATPCL during spermatogenesis. We also show that DmATPCL mutant meiotic phenotype is in part caused by a reduction of fatty acids, but not of triglycerides or cholesterol, indicating that DmATPCL-derived Acetyl-CoA is predominantly devoted to the biosynthesis of fatty acids during spermatogenesis. Collectively, our results unveil for the first time an involvement for DmATPCL in the regulation of meiotic cell division, which is likely conserved in human cells.

The Citrate Lyase (ACL) is the main cytosolic enzyme that converts the citrate exported from mitochondria by the SLC25A1 carrier in Acetyl Coenzyme A (acetyl-CoA) and oxaloacetate. Acetyl-CoA is a high-energy intermediate common to a large number of metabolic processes including protein acetylation reactions. This renders ACL a key regulator of histone acetylation levels and gene expression in diverse organisms including humans. We have found that depletion of ATPCL, the Drosophila ortholog of human ACL, reduced levels of Acetyl CoA but, unlike its human counterpart, does not affect global histone acetylation and gene expression. Nevertheless, reduced ATPCL levels caused evident, although moderate, mitotic chromosome breakage suggesting that this enzyme plays a partial role in chromosome stability. These defects did not increase upon X-ray irradiation, indicating that they are not dependent on an impairment of DNA repair. Interestingly, depletion of ATPCL drastically increased the frequency of chromosome breaks (CBs) associated to mutations in scheggia, which encodes the ortholog of the mitochondrial citrate carrier SLC25A1 that is also required for chromosome integrity and histone acetylation. Our results indicate that ATPCL has a dispensable role in histone acetylation and prevents massive chromosome fragmentation when citrate efflux is altered.

Introduction Poor data quality and use have been identified as key challenges that negatively impact immunization programs in low- and middle-income countries (LMICs). In addition, many LMICs have a shortage of health personnel, and staff available have demanding workloads across several health programs. In order to address these challenges, the Better Immunization Data (BID) Initiative introduced a comprehensive suite of interventions, including an electronic immunization registry aimed at improving the quality, reliability, and use of immunization data in Arusha Region, Tanzania, and Southern Province of Zambia. The objective of this study was to assess the incremental costs of implementing the BID interventions in immunization programs in these two countries. Methods We conducted a micro-costing study to estimate the economic costs of service delivery and logistics for the immunization programs with and without the BID interventions in a sample of health facilities and district program offices in each country. Structured questionnaires were used to interview immunization program staff at baseline and post-intervention to assess annual resource utilization and costs. Cost outcomes were reported as annual cost per facility, cost per district and changes in resource costs due to the BID interventions (i.e., costs associated with health worker time, start-up costs, etc.). Sub-group analyses were conducted by health facility to assess variation in costs by volume served and location (rural versus urban). One-way sensitivity analyses were conducted to identify influential parameters. Costs were reported in 2017 US dollars. Results In Tanzania, the average annual reduction in resource costs was estimated at US$10,236 (95% confidence interval: $7,606-$14,123) per health facility, while the average annual reduction in resource costs per district was estimated at $6,542. In Zambia, reductions in resource costs were modest at an estimated annual average of $628 (95% confidence interval: $209-$1,467) per health facility and $236 per district. Resource cost reductions were mainly attributable to reductions in time required for immunization service delivery and reporting. One-way sensitivity analyses identified key cost drivers, all related to reductions in health worker time. Conclusion The introduction of electronic immunization registries and stock management systems through the BID Initiative was estimated to result in potential time savings in both countries. Health worker time was the area most impacted by the interventions, suggesting that time savings gained could be utilized for patient care. Information generated through this work provides evidence to inform stakeholder decision-making for scale-up of the BID interventions in Tanzania and Zambia and to inform other Low-to-Middle-Income Countries (LMICs) interested in similar interventions.

ObjectiveTo determine the costs to develop, roll out and maintain electronic immunisation registries (EIRs) and a related suite of data use interventions.MethodsThe Better Immunisation Data (BID) Initiative conducted the activities from 2013 to 2018 in three regions in Tanzania and one province in Zambia. The Initiative’s financial records were used to account for the financial costs of designing and developing the EIRs, BID staff time, expenditures for rolling out the EIR systems and the related suite of interventions to health facilities, and recurrent costs. Total financial costs, cost per facility and cost per child were calculated in 2018 US$.FindingsTotal expenditures were ~US$4.2 million in Tanzania and US$3.6 million in Zambia. System design and development costs accounted for ~33% and 26% of the expenditures in each country, respectively, while BID staff costs accounted for 39% and 52%, respectively. Average expenditures per health facility for rolling out the EIR system were between US$709 and US$1320 for the Tanzania regions and US$2591 for Zambia. The annualised average expenditure per child was estimated to be between US$3.30 and US$3.81 for the regions in Tanzania and US$8.46 in Zambia. Expenditures per child were higher in Zambia partly because of a much smaller birth cohort compared with Tanzania.ConclusionOther countries may benefit from the investments made and lessons learnt in Tanzania and Zambia by leveraging these now existing EIR platforms and rollout strategies, and hence may be able to implement EIRs at lower costs than reported here.

Multicolor immunostaining analysis is often a desirable tool in cell biology for most researchers. Nonetheless, this is not an easy task and often not affordable by many laboratories as it might require expensive instrumentation and sophisticated analysis software. Here, we describe a simple protocol for performing sequential immunostainings on two different Drosophila specimens. Our strategy relies on an efficient and reproducible method for removal primary antibodies and/or fluorophore-conjugated secondary antibodies that does not affect antigene integrity. We show that alternation of multiple rounds of antibody incubation and removal on the same slide, followed by registration of the same DAPI-stained image, provides a simple framework for the sequential detection of several antigens in the same cell. Given that the sample fixation procedures used for Drosophila tissues are compatible with most specimen processing protocols, we can envisage that the multicolor immunostaining strategy presented here can be also adapted to different samples including mammalian tissues and/or cells. J. Cell. Physiol. 229: 683–687, 2014. © 2013 Wiley Periodicals, Inc.

Low-resource countries can greatly benefit from even small increases in efficiency of health service provision, supporting a strong case to measure and pursue efficiency improvement in low- and middle-income countries (LMICs). However, the knowledge base concerning efficiency measurement remains scarce for these contexts. This study shows that current estimation approaches may not be well suited to measure technical efficiency in LMICs and offers an alternative approach for efficiency measurement in these settings. We developed a simulation environment which reproduces the characteristics of health service production in LMICs, and evaluated the performance of Data Envelopment Analysis (DEA) and Stochastic Distance Function (SDF) for assessing efficiency. We found that an ensemble approach (ENS) combining efficiency estimates from a restricted version of DEA (rDEA) and restricted SDF (rSDF) is the preferable method across a range of scenarios. This is the first study to analyze efficiency measurement in a simulation setting for LMICs. Our findings aim to heighten the validity and reliability of efficiency analyses in LMICs, and thus inform policy dialogues about improving the efficiency of health service production in these settings.

Production of nanotechnology-based materials is increasing worldwide: it is essential to evaluate their potential toxicity. Among these nanomaterials, carbon nanotubes (CNTs) have tremendous potential in many areas of research and applications. We have investigated the cyto- and genotoxic effects of single and multi-walled CNTs (SWCNTs, MWCNTs) and carbon black (CB) on the mouse macrophage cell line RAW 264.7. Specifically we have investigated inflammatory response, release of tumor necrosis factor-α (TNF-α), intracellular reactive oxygen species (ROS) production, cell death (both necrosis and apoptosis), chromosomal aberrations and cellular ultrastructural alteration caused by CB, MWCNTs and SWCNTs. Our data confirm that both CNTs and CB are cyto and geno-toxic to RAW 264.7 mouse macrophages. CNTs exposure induced ROS release, necrosis and chromosomal aberrations but did not cause an inflammatory response. In addition CNTs induce ultrastructural damage and apoptosis. CNTs penetrate the cell membrane and individual MWCNTs are seen associated with the nuclear envelope.

Liposomes entrapping enzymes behave as small membrane bioreactors which can be used in biotechnological and biomedical applications. Furthermore, liposomes loading enzymes are being used as model to mimic cellular and subcellular organel behaviour. This work deals with the study of the kinetic behaviour of carbonic anhydrase (CA) entrapped in lipid vesicle. CA is nearly ubiquitous, being present in many tissues of different species, in cells, subcellular particles and membranes. The carbonic anhydrase entrapment in liposomes, as a function of the lipid cocktail used, was studied preliminarily. Then kinetics of carbon dioxide hydration reaction, catalysed by CA entrapped in liposomes, has been studied.