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The National Hospital Insurance Fund (NHIF) of Kenya was upgraded to improve access to healthcare for impoverished households, expand universal health coverage, and boost the uptake of essential reproductive, maternal, newborn and child health (RMNCH) services. However, premiums may be unaffordable for the poorest households. The Innovative Partnership for Universal Sustainable Healthcare (i -PUSH) programme targets low-income women and their households to improve their access to and utilization of quality healthcare, including RMNCH services, by providing subsidized, mobile phone-based NHIF coverage in combination with enhanced, digital training of community health volunteers and upgrading of health facilities. This study evaluated whether expanded NHIF coverage increased the accessibility and utilization of quality basic RMNCH services in areas where i -PUSH was implemented using a longitudinal cluster randomized controlled trial in Kakamega, Kenya. A total of 24 pair-matched villages were randomly assigned either to the treatment or the control group. Within each village, 10 eligible households (i.e. with a woman aged 15–49 years who was either pregnant or with a child <4 years old) were randomly selected. The study applied a difference-in-difference methodology based on a pooled cross-sectional analysis of baseline, midline and endline data, with robustness checks based on balanced panels and Analysis of Covariance methods. The analysis sample included 346 women, of whom 248 had had a live birth in the 3 years prior to any of the surveys, and 424 children aged 0–59 months. Improved NHIF coverage did not have a statistically significant impact on any of the RMNCH outcome indicators at midline nor endline. Uptake of RMNCH services, however, improved substantially in both control and treatment areas at endline compared to baseline. For instance, significant increases were observed in the number of antenatal care visits from baseline to midline (mean = 2.62–2.92, P  < 0.01) and delivery with a skilled birth attendant from baseline to midline (mean = 0.91–0.97, P  < 0.01). Expanded NHIF coverage, providing enhanced access to RMNCH services of unlimited duration at both public and private facilities, did not result in an increased uptake of care, in a context where access to basic public RMNCH services was already widespread. However, the positive overall trend in RMNCH utilization indicators, in a period of constrained access due to the COVID-19 pandemic, suggests that the other components of the i -PUSH programme may have been beneficial. Further research is needed to better understand how the provision of insurance, enhanced community health volunteer training and improved healthcare quality interact to ensure pregnant women and young children can make full use of the continuum of care. [ABSTRACT FROM AUTHOR]

School-based comprehensive sexuality education (CSE) can help adolescents acquire crucial knowledge and skills to achieve their full potential, particularly in low- and middle-income countries with higher rates of negative sexual and reproductive outcomes. While many low- and middle-income countries have developed CSE curricula, little is known about how these are implemented in the classroom. This multi-country mixed-methods study analysed challenges to the implementation of national CSE curricula in schools in Ghana, Kenya, Peru and Guatemala, based on surveys of secondary school principals, teachers and students aged 15-17 years, and in-depth interviews with central and local government, NGOs and youth organisations. In all four countries, inadequate teacher training remained a major hurdle to effective implementation, manifesting in teacher discomfort and inaccurate messaging. This was compounded by a lack of comprehensive teaching resources. CSE classes were focused mainly on biology at the expense of contraception, gender and rights, despite students' desire for greater coverage of these topics. Teaching methods lacked interactive activities necessary to develop skills and values. Findings offer useful lessons to improve school-level implementation in these and other countries facing similar challenges. Increasing teacher training and distributing comprehensive CSE materials responsive to adolescents' needs remain priorities in all countries.

Comprehensive sexuality education (CSE) is a key component of efforts to improve sexual and reproductive outcomes for young people. While many governments have established policies and curricula for CSE, there are no quantitative measures of the quality of their implementation in schools. We describe the construction of a school-level index to measure CSE implementation quality using data from Peru, Guatemala, Kenya and Ghana for validation. The composite index represents seven key components of a successful programme: range of topics, values imparted, teaching methods, teacher training, resources available, monitoring and evaluation, and the school environment. These components are combined into two sub-indices (curriculum content and implementation context), which together provide a summary index of implementation quality. We present scores for the seven components, the two sub-indices and the summary index for each country. Ghana scored highest on the summary index, while Guatemala scored lowest, but country rankings varied within the different components. The paper discusses the implications of the findings for improving school-based CSE in these countries. An assessment of the validity and reliability of the index indicates it can be used in other settings and could be a useful tool for educationalists, researchers and programme implementers to measure CSE implementation quality.

Acute malnutrition in children under 5 years is persistent in Eastern Africa's arid and semiarid lands. This study aimed to identify the drivers of acute malnutrition in Turkana and Samburu counties, Kenya. This was a population‐based longitudinal mixed‐methods observational study. Qualitative and quantitative data were collected at Wave 1, but only quantitative data were collected during follow‐up. Participants were a representative sample of children and their primary caregivers from households with children under 3 years at Wave 1. Anthropometric measurements of all children under 5 years in the sampled households were taken at Wave 1 (May to July 2021), and one child under 3 years was randomly selected for follow‐up about every 4 months over 2 years for six data collection waves. The study also collected data on sociodemographics; child feeding practices and morbidity; household water and food insecurity; shocks; coping strategies, social safety nets and economic safeguards; water, sanitation and hygiene; women's decision‐making and food consumption. Qualitative data were collected through community dialogues, focus group discussions, in‐depth interviews, photovoice and key informant interviews with mothers and fathers with children under 5 years, community leaders, county officials and staff of nongovernmental organisations. Data collection is complete and analysis is ongoing. The analysis includes thematic analysis of qualitative data and descriptive and multi‐variable regression analyses of quantitative data. [ABSTRACT FROM AUTHOR]

Objective To investigate whether sub-Saharan African countries have succeeded in reducing wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions. Methods We analysed survey data from 36 countries, grouped into Central, East, Southern and West Africa subregions, in which at least two surveys had been conducted since 1995. We calculated the composite coverage index, a function of essential maternal and child health intervention parameters. We adopted the wealth index, divided into quintiles from poorest to wealthiest, to investigate wealth-related inequalities in coverage. We quantified trends with time by calculating average annual change in index using a least-squares weighted regression. We calculated population attributable risk to measure the contribution of wealth to the coverage index. Findings We noted large differences between the four regions, with a median composite coverage index ranging from 50.8% for West Africa to 75.3% for Southern Africa. Wealth-related inequalities were prevalent in all subregions, and were highest for West Africa and lowest for Southern Africa. Absolute income was not a predictor of coverage, as we observed a higher coverage in Southern (around 70%) compared with Central and West (around 40%) subregions for the same income. Wealth-related inequalities in coverage were reduced by the greatest amount in Southern Africa, and we found no evidence of inequality reduction in Central Africa. Conclusion Our data show that most countries in sub-Saharan Africa have succeeded in reducing wealth-related inequalities in the coverage of essential health services, even in the presence of conflict, economic hardship or political instability. [phrase omitted] [phrase omitted] Objectif Determiner si les pays d'Afrique subsaharienne sont parvenus a reduire l'impact des inegalites de richesse sur la prise en charge des interventions de sante reproductives, maternelles et infantiles. Methodes Nous avons analyse des donnees d'enquetes menees dans 36 pays regroupe en sous-regions (Afrique centrale, Afrique de l'Est, Afrique australe et Afrique de l'Ouest). Au moins deux enquetes devaient dater d'apres 1995. Nous avons calcule l'indice de prise en charge composite en fonction de plusieurs parametres essentiels d'interventions de sante maternelle et infantile. Nous avons egalement adopte l'indice de richesse divise en quintiles, du plus pauvre au plus nanti, afin d'etudier l'impact des inegalites de richesse dans cette prise en charge. Nous avons quantifie les tendances par rapport au temps, en calculant l'evolution annuelle moyenne de l'indice a l'aide de la regression des moindres carres ponderes. Enfin, nous avons evalue le risque attribuable a la population pour mesurer la contribution de la richesse a l'indice de prise en charge. Resultats Nous avons remarque des differences considerables entre les quatre regions, avec un indice median de prise en charge composite allant de 50,8% en Afrique de l'Ouest a 75,3% en Afrique australe. Les inegalites liees a la richesse etaient tres repandues dans toutes les sous-regions; les plus fortes ont ete observees en Afrique de l'Ouest, les plus faibles en Afrique australe. Le revenu absolu n'est pas un indicateur valable car nous avons constate une meilleure prise en charge dans la sous-region d'Afrique australe (environ 70%) que dans celles d'Afrique centrale et d'Afrique de l'Ouest (environ 40%) pour des revenus equivalents. La majorite des inegalites de prise en charge liees a la richesse ont diminue en Afrique australe, et nous n'avons trouve aucune preuve de reduction des inegalites en Afrique centrale. Conclusion Nos donnees montrent que la plupart des pays d'Afrique subsaharienne ont reussi a attenuer les inegalites de prise en charge liees a la richesse pour les services de sante essentiels, meme en cas de conflit, de difficultes economiques ou d'instabilite politique. [phrase omitted] Objetivo Investigar si los paises del Africa subsahariana han logrado reducir las desigualdades relacionadas con la riqueza en la cobertura de las intervenciones sanitarias relativas a la salud reproductiva, materna, neonatal e infantil. Metodos Se analizaron los datos de las encuestas de 36 paises, agrupados en las subregiones de Africa central, oriental, meridional y occidental, en los que se habian realizado por lo menos dos encuestas desde 1995. Se calculo el indice compuesto de cobertura, en funcion de los parametros esenciales de las intervenciones sanitarias relativas a la salud maternoinfantil. Se adopto el indice de riqueza, dividido en quintiles de mas pobres a mas ricos, para investigar las desigualdades de cobertura relacionadas con la riqueza. Se cuantificaron las tendencias con el tiempo al calcular el cambio anual medio del indice por medio de una regresion por minimos cuadrados ponderados. Tambien se calculo el riesgo atribuible a la poblacion para medir la contribucion de la riqueza al indice de cobertura. Resultados Se observaron grandes diferencias entre las cuatro regiones, con un indice compuesto medio de cobertura que oscilaba entre el 50,8 % para el Africa occidental y el 75,3 % para el Africa meridional. Las desigualdades relacionadas con la riqueza prevalecian en todas las subregiones y eran mayores en el Africa occidental y menores en el Africa meridional. Los ingresos absolutos no eran un factor de prediccion de la cobertura, ya que se observo una mayor cobertura en las subregiones del sur (alrededor del 70 %) en comparacion con las subregiones central y occidental (alrededor del 40 %) para los mismos ingresos. Las desigualdades de cobertura relacionadas con la riqueza se redujeron en mayor medida en el Africa meridional, y no encontramos pruebas de reduccion de la desigualdad en el Africa central. Conclusion Estos datos muestran que la mayoria de los paises del Africa subsahariana han logrado reducir las desigualdades relacionadas con la riqueza en la cobertura de los servicios sanitarios esenciales, incluso en presencia de conflictos, dificultades economicas o inestabilidad politica., Introduction Reaching all women and children with essential reproductive, maternal, newborn and child health interventions is a critical part of universal health coverage, and is represented by the Global Strategy [...]

The successful implementation of comprehensive sexuality education (CSE) programmes in schools depends on the development and implementation of strong policy in support of CSE. This paper offers a comparative analysis of the policy environment governing school-based CSE in four low- and middle-income countries at different stages of programme implementation: Ghana, Peru, Kenya and Guatemala. Based on an analysis of current policy and legal frameworks, key informant interviews and recent regional reviews, the analysis focuses on seven policy-related levers that contribute to successful school-based sexuality education programmes. The levers cover policy development trends; current policy and legal frameworks for sexuality education; international commitments affecting CSE policies; the various actors involved in shaping CSE; and the partnerships and coalitions of actors that influence CSE policy. Our analysis shows that all four countries benefit from a policy environment that, if properly leveraged, could lead to a stronger implementation of CSE in schools. However, each faces several key challenges that must be addressed to ensure the health and wellbeing of their young people. Latin American and African countries show notable differences in the development and evolution of their CSE policy environments, providing valuable insights for programme development and implementation.

Background Epidemics can cause significant disruptions of essential health care services. This was evident in West-Africa during the 2014-2016 Ebola outbreak, raising concerns that COVID-19 would have similar devastating consequences for the continent. Indeed, official facility-based records show a reduction in health care visits after the onset of COVID-19 in Kenya. Our question is whether this observed reduction was caused by lower access to health care or by reduced incidence of communicable diseases resulting from reduced mobility and social contacts. Methods We analysed monthly facility-based data from 2018 to 2020, and weekly health diaries data digitally collected by trained filedworkers between February and November 2020 from 342 households, including 1974 individuals, in Kisumu and Kakamega Counties, Kenya. Diaries data was collected as part of an ongoing longitudinal study of a digital health insurance scheme (Kakamega), and universal health coverage implementation (Kisumu). We assessed the weekly incidence of self-reported medical symptoms, formal and informal health-seeking behaviour, and foregone care in the diaries and compared it with facility-based records. Linear probability regressions with household fixed-effects were performed to compare the weekly incidence of health outcomes before and after COVID-19. Results Facility-based data showed a decrease in health care utilization for respiratory infections, enteric illnesses, and malaria, after start of COVID-19 measures in Kenya in March 2020. The weekly diaries confirmed this decrease in respiratory and enteric symptoms, and malaria / fever, mainly in the paediatric population. In terms of health care seeking behaviour, our diaries data find a temporary shift in consultations from health care centres to pharmacists / chemists / medicine vendors for a few weeks during the pandemic, but no increase in foregone care. According to the diaries, for adults the incidence of communicable diseases/symptoms rebounded after COVID-19 mobility restrictions were lifted, while for children the effects persisted. Conclusions COVID-19-related containment measures in Western Kenya were accompanied by a decline in respiratory infections, enteric illnesses, and malaria / fever mainly in children. Data from a population-based survey and facility-based records aligned regarding this finding despite the temporary shift to non-facility-based consultations and confirmed that the drop in utilization of health care services was not due to decreased accessibility, but rather to a lower incidence of these infections. [ABSTRACT FROM AUTHOR]

Background: Universal Health Coverage ensures access to quality health services for all, with no financial hardship when accessing the needed services. Nevertheless, access to quality health services is marred by substantial resource shortages creating service delivery gaps in low-and middle-income countries, including Kenya. The Innovative Partnership for Universal Sustainable Healthcare (i-PUSH) program, developed by AMREF Health Africa and PharmAccess Foundation (PAF), aims to empower low-income women of reproductive age and their families through innovative digital tools. This study aims to evaluate the impact of i-PUSH on maternal and child health care utilization, women's health including their knowledge, behavior, and uptake of respective services, as well as women's empowerment and financial protection. It also aims to evaluate the impact of the LEAP training tool on empowering and enhancing community health volunteers' health literacy and to evaluate the impact of the M-TIBA health wallet on savings for health and health insurance uptake.Methods: This is a study protocol for a cluster randomized controlled trial (RCT) study that uses a four-pronged approach-including year-long weekly financial and health diaries interviews, baseline and endline surveys, a qualitative study, and behavioral lab-in-the-field experiments-in Kakemega County, Kenya. In total, 240 households from 24 villages in Kakamega will be followed to capture their health, health knowledge, health-seeking behavior, health expenditures, and enrolment in health insurance over time. Half of the households live in villages randomly assigned to the treatment group where i-PUSH will be implemented after the baseline, while the other half of the households live in control village where i-PUSH will not be implemented until after the endline. The study protocol was reviewed and approved by the AMREF Ethical and Scientific Review Board. Research permits were obtained from the National Commission for Science, Technology and Innovation agency of Kenya.Discussion: People in low-and middle-income countries often suffer from high out-of-pocket healthcare expenditures, which, in turn, impede access to quality health services. Saving for healthcare as well as enrolment in health insurance can improve access to healthcare by building capacities at all levels-individuals, families, and communities. Notably, i-PUSH fosters savings for health care through the mobile-phone based "health wallet," it enhances enrolment in subsidized health insurance through the mobile platform-M-TIBA-developed by PAF, and it seeks to improve health knowledge and behavior through community health volunteers (CHVs) who are trained using the LEAP tool-AMREF's mHealth platform. The findings will inform stakeholders to formulate better strategies to ensure access to Universal Health Coverage in general, and for a highly vulnerable segment of the population in particular, including low-income mothers and their children.Trial Registration: Registered with Protocol Registration and Results System (protocol ID: AfricanPHRC; trial ID: NCT04068571 : AEARCTR-0006089 ; date: 29 August 2019) and The American Economic Association's registry for randomized controlled trials (trial ID: AEARCTR-0006089; date: 26 June 2020). [ABSTRACT FROM AUTHOR]

School-based comprehensive sexuality education (CSE) can help adolescents achieve their full potential and realize their sexual and reproductive health and rights. This is particularly pressing in low- and middle-income countries (LMICs), where high rates of unintended pregnancy and STIs among adolescents can limit countries’ ability to capitalize on the demographic dividend. While many LMICs have developed CSE curricula, their full implementation is often hindered by challenges around program planning and roll-out at the national and local level. A better understanding of these barriers, and similarities and differences across countries, can help devise strategies to improve implementation; yet few studies have examined these barriers. This paper analyzes the challenges to the implementation of national CSE curricula in four LMICs: Ghana, Kenya, Peru and Guatemala. It presents qualitative findings from in-depth interviews with central and local government officials, civil society representatives, and community level stakeholders ranging from religious leaders to youth representatives. Qualitative findings are complemented by quantitative results from surveys of principals, teachers who teach CSE topics, and students aged 15–17 in a representative sample of 60–80 secondary schools distributed across three regions in each country, for a total of around 3000 students per country. Challenges encountered were strikingly similar across countries. Program planning-related challenges included insufficient and piecemeal funding for CSE; lack of coordination of the various efforts by central and local government, NGOs and development partners; and inadequate systems for monitoring and evaluating teachers and students on CSE. Curriculum implementation-related challenges included inadequate weight given to CSE when integrated into other subjects, insufficient adaptation of the curriculum to local contexts, and limited stakeholder participation in curriculum development. While challenges were similar across countries, the strategies used to overcome them were different, and offer useful lessons to improve implementation for these and other low- and middle-income countries facing similar challenges. [ABSTRACT FROM AUTHOR]

Background: Over six million induced abortions were reported in Africa in 2008 with over two million induced abortions occurring in Eastern Africa. Although a significant proportion of women in the region procure more than one abortion during their reproductive period, there is a dearth of research on factors associated with repeat abortion.Methods: Data for this study come from the Magnitude and Incidence of Unsafe Abortion Study conducted by the African Population and Health Research Center in Kenya in 2012. The study used a nationally-representative sample of 350 facilities (level II to level VI) that offer post-abortion services for complications following induced and spontaneous abortions. A prospective morbidity survey tool was used by health providers in 328 facilities to collect information on socio-demographic charateristics, reproductive health history and contraceptive use at conception for all patients presenting for post-abortion services. Our analysis is based on data recorded on 769 women who were classified as having had an induced abortion.Results: About 16 % of women seeking post abortion services for an induced abortion reported to have had a previous induced abortion. Being separated or divorced or widowed, having no education, having unwanted pregnancy, having 1-2 prior births and using traditional methods of contraception were associated with a higher likelihood of a repeat induced abortion.Conclusions: The findings point to the need to address the reasons why women with first time induced abortion do not have the necessary information to prevent unintended pregnancies and further induced abortions. Possible explanations linked to the quality of post-abortion family planning and coverage of long-acting methods should be explored. [ABSTRACT FROM AUTHOR]

Universal access to reproductive health services entails strengthening health systems, but requires significant resource commitments as well as efficient and effective use of those resources. A number of international organizations and governments in developing countries are putting efforts into tracking the flow of health resources in order to inform resource mobilization and allocation, strategic planning, priority setting, advocacy and general policy making. The UNFPA/NIDI-led Resource Flows Project ("The UNFPA/NIDI RF Project") has conducted annual surveys since 1997 to monitor progress achieved by developing countries in implementing reproductive health financial targets. This commentary summarizes the Project experiences and challenges in gathering data on allocation of resources for reproductive health at the domestic level in sub-Saharan African countries. One key lesson learnt from the Project experience is the need for strengthening tracking mechanisms in sub-Saharan African countries and making information on reproductive health resources and expenditures available, in particular the private sector resources. [ABSTRACT FROM AUTHOR]

Background: Expanding access to antiretroviral therapy (ART) means that HIV is no longer a death sentence. This change has implications for reproductive decisions and behaviors of HIV-infected individuals. Design: Using multiple rounds of biomarker data from Demographic and Health Surveys (20042012) in nine sub-Saharan African countries, we compare patterns of associations between HIV status and fertility intention and between current use of modern contraception and HIV status in the context of expanding ART coverage. Results: Generally, results show that knowledge of HIV status and proportion of women ever tested for HIV increased substantially between the two surveys for almost all countries. Whereas modern contraceptive use slightly increased, fertility intentions remained relatively stable, except for Rwanda, where they decreased. Results from the two surveys for the nine countries do however indicate that there is no clear consistent pattern of fertility intention and modern contraceptive use behavior by HIV status, with variations observed across countries. However, multivariate analyses show that for Rwanda and Zimbabwe women who were HIV positive, with knowledge of their status, had lower odds of wanting more children. Similarly only in Rwanda (both surveys) were HIV-positive women who knew their status more likely to be current users of contraception compared with women who were HIV negative. The reverse was observed for Zimbabwe. Conclusions: Generally, the results point to the fact that the assumption that reproductive intention and behavior of HIV-positive women will differ compared with that of HIV-negative women may only hold true to the extent that women know their HIV status. Continuous expansion of voluntary counseling and testing services and integration of HIV treatment and care services with reproductive health services are thus warranted. [ABSTRACT FROM AUTHOR]

Background: There is scanty evidence regarding the impact of parenting practices on young people's sexual risk-taking in sub-Saharan Africa. Moreover, the extent to which such practices have enduring consequences on adolescents and young adults is little documented. This study uses repeated measures of parent-child relationships, parental monitoring, and parent-child communication about sexual matters to shed some light in these two areas. Methods: The analysis is based on time-dependent retrospective data on parenting practices which were retrieved from the Cameroon Family and Health Survey (CFHS). The study sample includes 447 sexually active and unmarried individuals aged 15-24 years old. Correlation analysis and multivariate logistic regressions are used. Results: Young males and females reported high levels of parental monitoring, moderate quality of parent-child relationships and low levels of parent-child communication on sexual matters. This study substantiates that the higher the quality of parent-child relationships, the lower the odds of young males having multiple sexual partners (0.63, p < 0.05), and the lower the odds of young females being sexually active (0.52, p < 0.10) or of having multiple sexual partners (0.64, p < 0.10) or of having occasional sexual partners (0.51, p < 0.05). Living with the biological father only was associated with higher odds of having multiple sexual partners (3.21, p < 0.10) and higher odds of occasional concurrent sexual partners (3.26, p < 0.10) among young males. Compared with their out-of-school counterparts, young males still enrolled in school were less likely to be sexually active in the last 12 months (0.33, p < 0.05) and less likely to have occasional concurrent sexual partners (0.57, p < 0.10), whereas young females still enrolled in school were more likely to be sexually active (2.25, p < 0.10) and less likely to use contraceptive consistently (0.36, p < 0.001). Conclusions: Reproductive health programs and interventions for preventing young people's risky sexual behaviors in sub-Saharan African settings must take into account the protective effects of parent-child relationships and the significance of parental monitoring over time. [ABSTRACT FROM AUTHOR]

The article focuses on a study on providing comprehensive sexuality education to improve sexual and reproductive outcomes in adolescents. Topics discussed include monitoring and evaluation of teacher training and the school environment, associations of variation in the index within and between countries with students' knowledge, attitudes and behaviors, and differences between countries in program success.