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Introduction major external structural birth defects are typical and have been associated with childhood morbidity, mortality and lifelong resource-intensive disabilities. These defects continue to occur; however, they are yet to be recognized as public health problems in Kenya. The objective of this study was to estimate the prevalence of major external structural birth defects in Kiambu County in Kenya, 2014-2018. Methods a cross-sectional study design was adopted; a retrospective review of medical records was conducted between 2014 and 2018 abstracting 873 birth defects. Following a predetermined inclusion criterion, a five-year prevalence numerator of 362 cases was determined, whereas, a five-year prevalence denominator of 299,854 cases of registered live-births was obtained from the birth registrar. Annual prevalence estimates of 29 sub-groups and 6 groups of these defects were calculated as the number of cases (numerator) divided by the number of live-births (denominator). Associated 95% binomial exact confidence intervals were also computed and expressed per 100,000 live-births. Results defects of the musculoskeletal system, the central nervous system, orofacial, genital organs, eye and anus were observed. Defects of the musculoskeletal system were the most prevalent, ranging from 22.98 (95% CI: 11.87-40.13) to 116.9 (95% CI: 92.98-145.08) per 100,000 live-births. Defects of the central nervous system followed ranging between 13.40 (95% CI: 5.39-27.61) and 32.79 (95% CI: 20.79-49.19) per 100,000 live-births. Conclusion despite musculoskeletal system defects being the most common group, hypospadias; a defect of the male genital organ was the most prevalent among the sub-group of these defects.

Background: Major external structural birth defects are known to exert an enormous economic burden on individuals and health services; however, they have been vastly unappreciated and underprioritized as a public health problem in settings where cost analyses are limited. Objective: The objective of this study was to conduct a cost analysis of outpatient services for major external structural birth defects in selected hospitals in Kiambu County, Kenya. Methods: A hospital-based cross-sectional study design was adopted in four hospitals where an ingredient approach was used to retrospectively gather data on cost drivers for interventions consisting of castings, bracings, and tendonectomies for the under-fives from health care providers’ perspectives for a one-year time horizon (January 1st, 2018, to December 31st, 2018). The hospitals were selected for providing outpatient corrective and rehabilitative services to the under-fives. Prevalence-based morbidity data were extracted from outpatient occupational therapy clinic registers, whereas staff-time for the hospitals’ executives comprising the medical superintendents, chief nursing officers, orthopedic surgeons, and health administrative officers were gathered through face-to-face enquires from the occupational therapists being the closest proxies for the officers. Following a predefined inclusion criterion, 349 cases were determined, and associated cost drivers identified, measured, and valued (quantified) using prevailing market prices. The costs were categorized as recurrent, and unit economic costs calculated as average costs, expressed in U.S Dollars, and inflated to the U.S Dollar Consumer Price Index from January 2018 to December 2018. Results: The unit economic cost of all the cases was estimated at $1,139.73; and $1,143.51 for neural tube defects, $1,143.05 for congenital talipes equinovarus, and $1,109.81 for congenital pes planus. Conclusions: The highest economic burden of major external structural birth defects in the county was associated with neural tube defects, followed by congenital pes planus despite having the fewest caseloads.

Birth registration imposes major challenges in developing countries, with importance to rights, health and all levels of development. Despite targeted initiatives, often with focus on improved access and information, universal registration has been elusive. Using cross-sectional survey from Kenya, we provide new evidence for why parents may not register. We report high awareness, low barriers – however with over 50 per cent of children unregistered. We argue this is due to deliberate, informed choice by parents where they weigh perceived costs/benefits. We recommend new focus on this deliberation and policy piggybacking hospital delivery, vaccination and information and communications technology to re-balance parent decision.

The study aimed to describe the effect of an oral health education intervention on oral hygiene status and gingival inflammation among persons with HIV attending two comprehensive healthcare centres in Nairobi, Kenya. This was a quasi-experimental study of 195 participants (with 102 in the intervention group, and 93 serving as the control group) who were selected using stratified random sampling. The data were collected at baseline, at three months (review 1), and at six months (review 2) using an interviewer-administered World Health Organization clinical examination form. The prevalence of plaque among the participants in the intervention decreased from 70.6% to 18.6%, with a significant decrease in their mean plaque score, from 0.89 to 0.15. The prevalence of gingival inflammation in the intervention group decreased from 58.2% to 12.7%, with a significant decrease in the mean gingival score, from 0.66 to 0.11. No significant change in degree of oral hygiene and gingival inflammation was observed among the non-intervention group. There was a strong association between the change in the mean gingival score and the change in the mean plaque score between baseline and at six months for the intervention group. The regression analysis yielded a coefficient of determination (r2) of 0.76; therefore, 76% of the variation in change in gingival score was explained by the variables in the equation. Only the change in mean plaque score was a significant predictor of the change in gingival score.

Rotavirus infection is the single most common cause of acute gastroenteritis in children under five years of age. The costs of care and treatment for rotavirus gastroenteritis are high. The objective was to compute average cost of care for children admitted with rotavirus gastroenteritis. A survey was conducted in children admitted with a diagnosis of acute gastroenteritis in Nairobi, Kenya. These were recruited and followed up till discharge or death. The costs they incurred were collected and the average costs were calculated. We concluded that rotavirus gastroenteritis leads to considerable resource utilization in health care settings and the society.

Birth registration and obtaining physical birth certificates impose major challenges in developing countries, with impact on child and community health, education, planning, and all levels of development. However despite initiatives, universal registration is elusive, leading to calls for new approaches to understanding the decisions of parents. In this paper, we report results of a survey of students in grades six to eight (age ~12–16) in an under-registered area of Kenya regarding their own understanding of registration issues and their suggestions for improvement. These students were selected because they themselves were also nearing the age for high school enrollment/entrance examinations, which specifically requires possession of a birth certificate. This assessment was also a companion to our previous representative survey of adults in the same Kenyan region, allowing for parent-child comparison. Results supported previous research, showing that only 43% had birth certificates. At the same time, despite these low totals, students were themselves quite aware of registration factors and purposes. The students also made quite prescient sources for understanding their households’ motivations, with many of their suggestions—for focus on communication of pragmatic benefits, or automatic measures shifting responsibility from parents—mirroring our own previous suggestions, and showing a level of pragmatism not witnessed when surveying their parents. This paper therefore adds evidence to the discussion of registration policy planning. More generally, it also builds on an important trend regarding the treatment of children as stakeholders and important sources of information, and raising an intriguing new avenue for future research.

ideas that PWAs have supernatural powers that can be obtained by ingesting their body parts, and that having sexual intercourse with females with albinism can cure HIV/AIDS. Improving awareness of albinism is an integral step towards improving quality of life of PWAs in Tanzania. We developed a program to evaluate the use of community health workers (CHWs) to spread awareness of albinism and the challenges faced by this marginalized population in Tanzania. Structure/Method/Design: We developed an educational program consisting of a video, PowerPoint presentation, and discussion topics and taught it to 33 CHWs trained by Empower Tanzania, an NGO with an infrastructure designed to disseminate public health practices in rural Tanzania. These CHWs delivered the presentation at schools and community gatherings in a rural district of Tanzania throughout February 2014. We administered questionnaires to program attendees before and after the presentation. We also gave questionnaires throughout the community before and after the month-long intervention. These questionnaires were used to assess baseline views about albinism, to evaluate the program’s success, and to obtain additional feedback. Outcomes & Evaluation: A total of 12,007 participants attended presentations. Questionnaires randomly administered to 426 participants demonstrated significantly higher knowledge about albinism after the presentations than before, and indicated that participants intended to share what they had learned with friends and family members. Community questionnaires administered to 896 randomlyselected community members in January and 743 additional community members in March suggested retained, community-wide gains in knowledge about albinism and the unique challenges faced by PWAs. Data analysis revealed the knowledge gains varied based on selected demographic characteristics. We conclude the program to be an effective means to improve awareness of and knowledge about albinism. We hope these knowledge gains can reduce the associated discrimination and stigma towards PWAs in Tanzania. Going Forward: The UN has identified improving knowledge at a community level as a priority in addressing violence towards Tanzanians with albinism. Public health interventions utilizing CHWs are an effective tool to improve health outcomes in rural populations. Our program demonstrates a promising approach to alleviate the challenges faced by a marginalized population and supports the utility of CHW programs to enact cultural change. This program will continue to be used by Empower Tanzania to maintain the observed gains in knowledge. Potential applications of our findings include dissemination of this program to other areas of Tanzania and utilization of this CHWbased approach to develop interventions addressing other social determinants of health in developing countries. Funding: Peterson Family Foundation Abstract #: 01ETC098

We use a quantile regression method to analyse the demand effects of user fees over the entire distribution of visits in a sample of rural and urban populations controlling for other covariates of interest, notably income and demographics. We find that the negative effects of fees on attendance differ across the visit quantiles, with the smallest effects being felt at higher quantiles. The main contribution of the paper is to show the non-uniform effects of fees at different points of the visits distribution, in contrast to the average effect computed using the OLS method. The policy implications of the findings are briefly discussed. Resume: Les auteurs du present article utilisent une methode de regression quantile pour analyser l’incidence des frais imposes aux usagers des services de sante sur la demande de soins medicaux, en fonction de la repartition globale des visites effectuees par un echantillon de la population rurale et urbaine, et verifier d’autres co-variables importantes, telles que le revenu et la demographie. Ils estiment que les effets negatifs des frais imposes aux usagers sur leur frequentation des centres de sante varient selon le nombre de fois ou ceux-ci se rendent dans ces centres, car plus leur taux de frequentation est eleve, plus ces effets negatifs sont insignifiants. La presente etude a pour principal objet de montrer les effets non uniformes des frais imposes aux usagers, a differents points de repartition de leur frequentation des centres de sante, par opposition aux effets moyens calcules selon la methode OLS. Elle traite brievement de l’incidence des resultats obtenus sur les politiques generales.

Medical insurance is an important feature of a health care system in which patients pay user charges to get medical treatment. Without insurance, many people would not afford acceptable care in a fee-for-service system. Since health is a merit good, making insurance broadly available in communities is a major policy issue in countries where user fees finance medical treatments. The paper analyses data from facility and household surveys in Kenya and shows that policies which popularize medical insurance can be inefficient because there exist community and household level factors that inhibit its use. The results further reveal substantial variations in the way the variables that influence the use of insurance affect different population sub-groups. In this regard, it is important to ensure that vulnerable groups in communities are not excluded from insurance schemes in which they invest. The policy value of the paper is to call attention to factors such as place of residence, gender, income, education, community institutions, transaction costs and facility quality – that hinder or facilitate use of medical insurance so that these factors can be considered when institutionalizing insurance in communities. We note that using the community as a unit of analysis in field surveys may strengthen policy conclusions usually obtained from such surveys. L’assurance medicale constitue un element important de tout systeme de soins de sante dans lequel les patients paient pour obtenir des soins medicaux. Sans assurance, de nombreuses personnes seraient dans l’incapacie de faire face aux couts d’un systeme de paiement a l’acte. La santeetant un bien tutelaire, generaliser l’acces a l’assurance au sein des communautes est une question politique majeure dans les pays ou les soins medicaux sont finances par les utilisateurs. S’appuyant sur l’analyse des donnees d’enquetes dans les institutions sanitaires et aupres des menages kenyans, l’article montre que les politiques qui visent a generaliser l’assurance medicale peuventetre inefficaces parce que certains facteurs aux niveaux des communautes et des menages en inhibent l’utilisation. Il revele egalement de fortes disparites dans la faµon dont les variables qui influencent l’utilisation de l’assurance affectent differentes sous-sections de la population. A cet egard, il est important de veiller a ce que les groupes vulnerables ne soient pas exclus des plans d’assurance dans lesquels les communautes investissent. S’agissant des politiques a mettre en oeuvre, l’interet de cet article est qu’il attire l’attention sur des facteurs tels que le lieu de residence, le genre, le revenu, l’education, les institutions communautaires, les couts de transaction et la qualite des infrastructures, lesquels entravent ou facilitent l’utilisation de l’assurance medicale, et pourraient etre pris en compte lorsque l’on institutionnalise l’assurance dans les communautes. Il est a noter qu’utiliser la communaute comme unite d’analyse des enquetes de terrain peut renforcer les conclusions qu’engendrent generalement ce type d’enquetes.

The paper analyzes household expenditure on medical care and the willingness to contribute towards service improvements at government health facilities. The analysis is based on survey data from two rural districts in Kenya situated approximately four hundred miles apart. The main finding is that medical care expenditure rises as household income increases, but the probability of willingness to pay fees for service improvement at government clinics declines with income. Income is an important determinant of the willingness to participate in a hypothetical government insurance scheme, with the probability of participation falling as income rises. These results should be interpreted with caution because of the potential for incorrect reporting of the willingness to pay for services that have an element of a social good. The policy implications of the results are briefly discussed.

In December 1989, the Government of Kenya implemented cost sharing reforms in a substantial portion of public health facilities. In September 1990 the Government suspended registration fees for out‐patient treatments, but reintroduced them in April 1992 after a lapse of a 20‐month period. Assesses the effects of these policy changes on demand for out‐patient services using a small data set from a rural district in central Kenya. Finds that, although medical services are inelastic with respect to user charges, cost sharing led to a significant reduction in out‐patient attendance: demand for out‐patient care declined by about 40 per cent. Consistent with this finding, suspension of registration fees in 1990 is associated with a 30 per cent increase in attendance. This increase occurred despite the retention of fees for diagnostic services. By March 1991, seven months after the suspension of fees, service demand had recovered remarkably and was only about 20 per cent below its original level. Further, finds that patients are more sensitive to fees for diagnostic services than they are to registration fees.

During the decade and a half after Alma Ata hundreds of projects were started in developing countries to implement the principles of PHC and start community based health care programs in the rural areas of developing countries. Until the past five years urban health was not seen as a special health problem. Population pressure in the rural areas has created shortages of land, food and employment opportunities. These forces have generated major population movements to the urban centres. The population movements have encouraged unprecedented expansion of urban centres. This sudden concentration of large populations in small geographical areas has resulted in the urban health crises of the developing world. The poor who live in the slum areas have no access to adequate health services, they experience frequent epidemics of communicable diseases like cholera, they live within a heavily polluted environment, and their children have very poor health because they are not immunized and are malnourished. The paper agrees with approaches which have been championed by development agencies to address the urban health crises. These approaches propose the reorientation of urban health systems to include adoption of PHC for urban health programs, intersectoral collaboration and extra budgetary support. The paper argues for further strengthening of the reorientation approach by adjusting the development planning model. It is proposed that the urban plan be integrated into the national development plan so that emerging urban health crises can receive special attention in resource allocation.

Background: Rotavirus infection is the single most common cause of acute gastroenteritis in children under five years of age. Rotavirus gastroenteritis has a high morbidity and mortality in children in Kenya. Objectives: To determine the short term clinical outcome for children admitted to Kenyatta National Hospital with rotavirus gastroenteritis and the correlates of poor outcome. Design: Short longitudinal survey. Setting: Kenyatta National Hospital from February to May 2008. Subjects: Five hundred children were screened using a rapid antigen detection kit and ELISA. Results: Of the 191 children who tested positive for rotavirus in stool; 172 children were recruited into the study. Eighty eight per cent of the patients were discharged within one week, 8.1% stayed for more than seven days while 4.1% died. Children who had co-morbidities such as malnutrition, rickets and pneumonia had worse outcomes. Conclusion: Rotavirus gastroenteritis has a long hospital stay and a high mortality. Children in shock on admission and those with co-morbid conditions should get priority for they have a poor outcome.

The study aims to determine the resource gaps in the delivery of MEHSP at the district health system.Cross sectional survey.District health system, Coast Province, Kenya.A sample of 11 district health system facilities.Resource gaps analysis shows that service provision is sensitive to dominant inputs (availability of buildings, equipment, personnel, drugs and non-pharmaceuticals) at all levels of care. Targeting of the resources in respect of the important inputs is poor at all levels as demonstrated by the wide range of excess and shortages of inputs. The mismatch may have adverse effects on both quantity and quality of services.A deliberate policy for targeting of finances for the important inputs needs to be developed to ensure optimisation of their combinations for minimization of mismatch of resources.

Objective: To assess the relationship between maternal factors and child nutritional status among children aged 6-36 months. Design: Cross sectional descriptive survey. Setting: Urban slum settlement in Nairobi, Kenya. Subjects: This study included a random sample of 369 households of mothers with children aged 6-36 months at the time of the study. Results: Maternal factors which showed a positive significant association with at least one of the three child nutritional status indicators (height for age, weight for age and weight for height) were birth spacing, parity, maternal education level and mothers marital status. Child spacing and parity emerged as the most important predictors of stunting among study children. Maternal nutritional status was also shown to be positively associated with child nutritional status. Maternal ill health had a negative effect on child nutritional status. Conclusion: Maternal factors are an underlying cause of childhood malnutrition. East African Medical Journal Vol.82(4) 2005: 209-215

Provision of mortuary services free of charge in a government hospital in rural Kenya is found to have led to a black market trade in these services. The principal participants in the market were the mortuary attendants and bereaved families. A method is developed for determining black market expenditures on mortuary services at a government hospital. On average, a bereaved family spent about US $2.30 on mortuary services. Burial expenses were also substantial, amounting to some US $75 per bereaved family. It is shown that free provision of mortuary services in government hospitals has a hidden cost, that could exceed the fee that users can be expected to pay openly.

This paper studies the problem of malaria control in irrigation and non-irrigation areas in Kenya. Empirical results show that in both areas, households' level of awareness of malaria as a health problem, including its cause, was very high. However, attempts to trace the direct effects of malaria upon income or upon agricultural production were not statistically important. This does not imply that malaria has no consequence on household welfare. It is possible that the model equations were mis-specified--aggregate variables (total family size, total family income) and failure to quantify land in the production relationships may have contributed to these results. In addition, poor separation of malaria as a disease, from malaria as an infection, may have underestimated the effect of the disease on production. Thirdly, labour substitution (hiring or within-family substitution) was not measured in this early study, but was taken into account in subsequent research. Finally, labour requirements in the annual crop production schedules and the co-relation between these labour requirements and the pattern of adult morbidity were not longitudinally monitored. Cross-section data would bias the findings, particularly in those areas where the peak transmission season is short, where the crop grown does not require major labour input during this transmission season, and where acquisition of immunity would reduce the clinical impact of malaria upon adult labour. These vulnerabilities in the specification of the model and the data collected, probably affect the results obtained. Our empirical work raises a number of interesting and important questions which should be taken into account in future research.

This paper describes the methodology and presents preliminary results of an economic appraisal of a community based health care project in Kenya. Community health workers, trained for 12 weeks and deployed in two locations in Kenya's Western Province, act as first contact providers of basic health care and promoters of selected health, sanitation and nutrition practices. A Cost Benefit Analysis has been undertaken using the Willingness to Pay approach to compare the costs of the project and its benefits. The benefits are in the form of more easily accessible basic health care and are measured as consumer surplus accruing to the community. Gain in consumer surplus is consequent on the fall of average user costs and rise in utilisation of the project established points of first contact with primary health care. The argument for the economic viability of the project is validated by the large Net Present Value and Benefit Cost Ratio obtained for the whole of the project area and for the two locations separately. Although the evaluation technique used faces the problem of valuation of community time, aggregation of health care services at all points of first contact and the partial nature of cost benefit analysis evaluations, the results are strongly in favour of decentralisation of primary health care on similar lines in the rest of the country.

Essential drug schemes in the Third World countries face many problems. These include dependency on imported drugs in the face of chronic shortages of foreign exchange, inadequate manpower and technical capability for selection and procurement of drugs, competition between generic and brand drugs, weak local drug procurement and distribution systems and inability to commence local manufacturing even in situations where there may exist comparative advantage. Many of these problems relate to each other and are compounded by the domination of the pharmaceutical industry by multinational firms. Third World countries are in a very weak position in the international pharmaceutical industry. It is suggested that the essential drug situation would improve in Third World countries if certain strategies and policies were adopted. These include: intensification of personnel training in pharmaceuticals, deliberate use of generic drugs rather than brand name drugs, the involvement of the public sector in the procurement and distribution of drugs, buying drugs in bulk, changing drug prescription and consumption practices through continuous education, changing or instituting regulations to guard against unfavourable patents and commencing domestic production of essential drugs where this is not in conflict with the principle of comparative advantage.

Background Scaling up services to achieve HIV targets will require that countries optimize the use of available funding. Robust unit cost estimates are essential for the better use of resources, and information on the heterogeneity in the unit cost of delivering HIV services across facilities – both within and across countries – is critical to identifying and addressing inefficiencies. There is limited information on the unit cost of HIV prevention services in sub-Saharan Africa and information on the heterogeneity within and across countries and determinants of this variation is even more scarce. The “Optimizing the Response in Prevention: HIV Efficiency in Africa” (ORPHEA) study aims to add to the empirical body of knowledge on the cost and technical efficiency of HIV prevention services that decision makers can use to inform policy and planning. Methods/Design ORPHEA is a cross-sectional observational study conducted in 304 service delivery sites in Kenya, Rwanda, South Africa, and Zambia to assess the cost, cost structure, cost variability, and the determinants of efficiency for four HIV interventions: HIV testing and counselling (HTC), prevention of mother-to-child transmission (PMTCT), voluntary medical male circumcision (VMMC), and HIV prevention for sex workers. ORPHEA collected information at three levels (district, facility, and individual) on inputs to HIV prevention service production and their prices, outputs produced along the cascade of services, facility-level characteristics and contextual factors, district-level factors likely to influence the performance of facilities as well as the demand for HIV prevention services, and information on process quality for HTC, PMTCT, and VMMC services. Discussion ORPHEA is one of the most comprehensive studies on the cost and technical efficiency of HIV prevention interventions to date. The study applied a robust methodological design to collect comparable information to estimate the cost of HTC, PMTCT, VMMC, and sex worker prevention services in Kenya, Rwanda, South Africa, and Zambia, the level of efficiency in the current delivery of these services, and the key determinants of efficiency. The results of the study will be important to decision makers in the study countries as well as those in countries facing similar circumstances and contexts.