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Bakibinga P, Kisia L, Atela M, Kibe PM, Kabaria C, Kisiangani I, Kyobutungi C. Demand and supply-side barriers and opportunities to enhance access to healthcare for urban poor populations in Kenya: a qualitative study. BMJ Open 2022; 12:e057484. [PMID: 35523490 PMCID: PMC9083429 DOI: 10.1136/bmjopen-2021-057484] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To explore the barriers to and options for improving access to quality healthcare for the urban poor in Nairobi, Kenya. DESIGN AND PARTICIPANTS This was a qualitative approach. In-depth interviews (n=12), focus group discussions with community members (n=12) and key informant interviews with health providers and policymakers (n=25) were conducted between August 2019 and September 2020. Four feedback and validation workshops were held in December 2019 and April-June 2021. SETTING Korogocho and Viwandani urban slums in Nairobi, Kenya. RESULTS The socioe-conomic status of individuals and their families, such as poverty and lack of health insurance, interact with community-level factors like poor infrastructure, limited availability of health facilities and insecurity; and health system factors such as limited facility opening hours, health providers' attitudes and skills and limited public health resources to limit healthcare access and perpetuate health inequities. Limited involvement in decision-making processes by service providers and other key stakeholders was identified as a major challenge with significant implications on how limited health system resources are managed. CONCLUSION Despite many targeted interventions to improve the health and well-being of the urban poor, slum residents are still unable to obtain quality healthcare because of persistent and new barriers due to the COVID-19 pandemic. In a devolved health system, paying attention to health services managers' abilities to assess and respond to population health needs is vital. The limited use of existing accountability mechanisms requires attention to ensure that the mechanisms enhance, rather than limit, access to health services for the urban slum residents. The uniqueness of poor urban settings also requires in-depth and focused attention to social determinants of health within these contexts. To address individual, community and system-level barriers to quality healthcare in this and related settings and expand access to health services for all, multisectoral strategies tailored to each population group are needed.
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Affiliation(s)
| | - Lyagamula Kisia
- African Population and Health Research Center, Nairobi, Kenya
| | - Martin Atela
- Peterhouse, University of Cambridge, Cambridge, UK
- Research & Policy Unit, Partnership for African Social and Governance Research, Nairobi, Kenya
| | - Peter M Kibe
- African Population and Health Research Center, Nairobi, Kenya
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Wong KL, Banke-Thomas A, Sholkamy H, Dennis ML, Pembe AB, Birabwa C, Asefa A, Delamou A, Sidze EM, Dossou JP, Waiswa P, Beňová L. Tale of 22 cities: utilisation patterns and content of maternal care in large African cities. BMJ Glob Health 2022; 7:bmjgh-2021-007803. [PMID: 35232813 PMCID: PMC8889454 DOI: 10.1136/bmjgh-2021-007803] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/27/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction Globally, the majority of births happen in urban areas. Ensuring that women and their newborns benefit from a complete package of high-quality care during pregnancy, childbirth and the postnatal period present specific challenges in large cities. We examine health service utilisation and content of care along the maternal continuum of care (CoC) in 22 large African cities. Methods We analysed data from the most recent Demographic and Health Survey (DHS) since 2013 in any African country with at least one city of ≥1 million inhabitants in 2015. Women with live births from survey clusters in the most populous city per country were identified. We analysed 17 indicators capturing utilisation, sector and level of health facilities and content of three maternal care services: antenatal care (ANC), childbirth care and postnatal care (PNC), and a composite indicator capturing completion of the maternal CoC. We developed a categorisation of cities according to performance on utilisation and content within maternal CoC. Results The study sample included 25 326 live births reported by 19 217 women. Heterogeneity in the performance in the three services was observed across cities and across the three services within cities. ANC utilisation was high (>85%); facility-based childbirth and PNC ranged widely, 77%–99% and 29%–94%, respectively. Most cities showed inconsistent levels of utilisation and content across the maternal CoC, Cotonou and Accra showed relatively best and Nairobi and Ndjamena worst performance. Conclusion This exploratory analysis showed that many DHS can be analysed on the level of large African cities to provide actionable information about the utilisation and content of the three maternal health services. Our comparative analysis of 22 cities and proposed typology of best and worst-performing cities can provide a starting point for extracting lessons learnt and addressing critical gaps in maternal health in rapidly urbanising contexts.
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Affiliation(s)
- Kerry Lm Wong
- Infectious Disease and Epidemiology, London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
| | | | - Hania Sholkamy
- Social Research Center, American University in Cairo, Cairo, Egypt
| | | | - Andrea B Pembe
- Obstetric and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | | | - Anteneh Asefa
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Alexandre Delamou
- Department of Public Health, Universite Gamal Abdel Nasser de Conakry, Conakry, Guinea
| | | | - Jean-Paul Dossou
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium.,Public Health, Centre de recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
| | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Lenka Beňová
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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Wambiya EOA, Otieno PO, Mutua MK, Donfouet HPP, Mohamed SF. Patterns and predictors of private and public health care utilization among residents of an informal settlement in Nairobi, Kenya: a cross-sectional study. BMC Public Health 2021; 21:850. [PMID: 33941131 PMCID: PMC8091493 DOI: 10.1186/s12889-021-10836-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/13/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Knowledge of health care utilization is important in low-and middle-income countries where inequalities in the burden of diseases and access to primary health care exist. Limited evidence exists on health seeking and utilization in the informal settlements in Kenya. This study assessed the patterns and predictors of private and public health care utilization in an urban informal settlement in Kenya. METHODS This study used data from the Lown scholars study conducted between June and July 2018. A total of 300 households were randomly selected and data collected from 364 household members who reported having sought care for an illness in the 12 months preceding the study. Data were collected on health-seeking behaviour and explanatory variables (predisposing, enabling, and need factors). Health care utilization patterns were described using proportions. Predictors of private or public health care use were identified using multinomial logistic regression with the reference group being other providers. RESULTS Majority of the participants used private (47%) and public facilities (33%) with 20% using other providers including local pharmacies/drug shops and traditional healers. In the model comparing public facilities vs other facilities, members who were satisfied with the quality of health care (vs not satisfied) were less likely to use public facilities (adjusted relative risk ratio (aRRR) 0.29; CI 0.11-0.76) while members who reported an acute infection (vs no acute infection) were more likely to use public facilities (aRRR 2.31; 95% CI 1.13-4.99) compared to other facilities. In the second model comparing private facilities to other facilities, having health insurance coverage (aRRR 2.95; 95% CI 1.53-5.69), satisfaction with cost of care (aRRR 2.08; CI 1.00-4.36), and having an acute infection (aRRR 2.97; 95% CI 1.50-5.86) were significantly associated with private facility use compared to other facilities. CONCLUSIONS The majority of urban informal settlement dwellers seek care from private health facilities. As Kenya commits to achieving universal health coverage, interventions that improve health care access in informal and low-resource settlements are needed and should be modelled around enabling and need factors, particularly health care financing and quality of health care.
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Affiliation(s)
- Elvis O. A. Wambiya
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
| | - Peter O. Otieno
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
| | - Martin Kavao Mutua
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
| | - Hermann Pythagore Pierre Donfouet
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
| | - Shukri F. Mohamed
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
- Department of Global Health and Population, Lown Scholars Program, Harvard T.H. Chan School of Public Health, Boston, MA USA
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The Nairobi Urban Health and Demographic Surveillance of slum dwellers, 2002–2019: Value, processes, and challenges. GLOBAL EPIDEMIOLOGY 2020. [DOI: 10.1016/j.gloepi.2020.100024] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Iddi S, Kadengye DT, Kiwuwa-Muyingo S, Mutua MK, Asiki G. Associated factors of pregnancy loss in two urban slums of Nairobi: A generalized estimation equations approach. GLOBAL EPIDEMIOLOGY 2020. [DOI: 10.1016/j.gloepi.2020.100030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Syengo M, Suchman L. Private Providers' Experiences Implementing a Package of Interventions to Improve Quality of Care in Kenya: Findings From a Qualitative Evaluation. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:478-487. [PMID: 33008859 PMCID: PMC7541106 DOI: 10.9745/ghsp-d-20-00034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 07/07/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Quality of care is an important element in health care service delivery in low- and middle-income countries. Innovative strategies are critical to ensure that private providers implement quality of care interventions. We explored private providers' experiences implementing a package of interventions intended to improve the quality of care in small and medium-sized private health facilities in Kenya. METHODS Data were collected as part of the qualitative evaluation of the African Health Markets for Equity (AHME) program in Kenya between June and July 2018. Private providers were purposively selected from 2 social franchise networks participating in AHME: the Amua network run by Marie Stopes Kenya and the Tunza network run by Population Services Kenya. Individual interviews (N=47) were conducted with providers to learn about their experiences with a package of interventions that included social franchising, SafeCare (a quality improvement program), National Hospital Insurance Fund (NHIF) accreditation assistance, and business support. RESULTS Private providers felt they benefited from trainings in clinical methods and quality improvement offered through AHME. Providers especially appreciated the mentorship and guidelines offered through programs like social franchising and SafeCare, and those who received support for NHIF accreditation felt they were able to offer higher quality services after going through this process. However, quality improvement was sometimes prohibitively expensive for private providers in smaller facilities that already realize relatively low revenue and the NHIF accreditation process was difficult to navigate without the help of the AHME partners due to complexity and a lack of transparency. CONCLUSION Our findings suggest that engaging private providers in a comprehensive package of quality improvement activities is achievable and may be preferable to a simpler program. However, further research that looks at the implications for cost and return on investment is required.
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Affiliation(s)
| | - Lauren Suchman
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA
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Effect of maternal nutritional education and counselling on children's stunting prevalence in urban informal settlements in Nairobi, Kenya. Public Health Nutr 2020; 24:3740-3752. [PMID: 32693855 DOI: 10.1017/s1368980020001962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine whether the prevalence of stunting differed between an intervention group and a control group and to identify factors associated with the children's linear growth. DESIGN This was a follow-up study of mother-child pairs who participated in a 2012-2015 cluster randomised controlled trial. Linear mixed effects models were performed to model the children's linear growth and identify the determinants of child linear growth. SETTING The study was conducted in two slums in Nairobi. The intervention group received monthly nutrition education and counselling (NEC) during pregnancy and infancy period. PARTICIPANTS A birth cohort of 1004 was followed up every 3 months after delivery to the 13th month. However, as a result of dropouts, a total of 438 mother-child pairs participated during the 55-month follow-up. The loss to follow-up baseline characteristics did not differ from those included for analysis. RESULTS Length-for-age z-scores decreased from birth to the 13th month, mean -1·42 (sd 2·04), with the control group (33·5 %) reporting a significantly higher prevalence of stunting than the intervention group (28·6 %). Conversely, the scores increased in the 55th month, mean -0·89 (sd 1·04), with significantly more males (16·5 %) stunted in the control group than in the intervention group (8·3 %). Being in the control group, being a male child, often vomiting/regurgitating food, mother's stature of <154 cm and early weaning were negatively associated with children's linear growth. CONCLUSIONS Home-based maternal NEC reduced stunting among under five years; however, the long-term benefits of this intervention on children's health need to be elucidated.
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Gharaee H, Tabrizi JS, Azami-Aghdash S, Farahbakhsh M, Karamouz M, Nosratnejad S. Analysis of Public-Private Partnership in Providing Primary Health Care Policy: An Experience From Iran. J Prim Care Community Health 2020; 10:2150132719881507. [PMID: 31617451 PMCID: PMC6796199 DOI: 10.1177/2150132719881507] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background: This study aims to analyze the public-private
partnership (PPP) policy in primary health care (PHC), focusing on the
experience of the East Azerbaijan Province (EAP) of Iran. Methods:
This research is a qualitative study. Data were gathered using interviews with
stakeholders and document analysis and analyzed through content analysis.
Results: Participants considered political and economic support
as the most important underlying factors. Improving system efficiency was the
main goal of this policy. Most stakeholders were supporters of the plan, and
there was no major opponent. Implementing the health evolution plan (HEP) was an
opportunity to design this policy. Participants considered the lack of provision
of infrastructure as the main weakness, changing the role of the public sector
as the main strength, and promoting social justice as the main achievement of
policy. The results of the quantitative data review showed that following the
implementation of this policy, health indicators have been improved.
Conclusions: Based on the results of this study, the PPP model
in EAP is a new and successful experience in PHC in Iran. Supporting and
developing this policy may improve the quality and quantity of providing
care.
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Faye CM, Fonn S, Kimani‐Murage E. Family influences on child nutritional outcomes in Nairobi's informal settlements. Child Care Health Dev 2019; 45:509-517. [PMID: 30986888 PMCID: PMC6563089 DOI: 10.1111/cch.12670] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 04/07/2019] [Accepted: 04/11/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Improving child nutritional status is an important step towards achieving the Sustainable Development Goals 2 and 3 in developing countries. Most child nutrition interventions in these countries remain variably effective because the strategies often target the child's mother/caregiver and give limited attention to other household members. Quantitative studies have identified individual level factors, such as mother and child attributes, influencing child nutritional outcomes. METHODS We used a qualitative approach to explore the influence of household members on child feeding, in particular, the roles of grandmothers and fathers, in two Nairobi informal settlements. Using in-depth interviews, we collected data from mothers of under-five children, grandmothers, and fathers from the same households. RESULTS Our findings illustrate that poverty is a root cause of poor nutrition. We found that mothers are not the sole decision makers within the household regarding the feeding of their children, as grandmothers appear to play key roles. Even in urban informal settlements, three-generation households exist and must be taken into account. Fathers, however, are described as providers of food and are rarely involved in decision making around child feeding. Lastly, we illustrate that promotion of exclusive breastfeeding for 6 months, as recommended by the World Health Organization, is hard to achieve in this community. CONCLUSIONS These findings call for a more holistic and inclusive approach for tackling suboptimal feeding in these communities by addressing poverty, targeting both mothers and grandmothers in child nutrition strategies, and promoting environments that support improved feeding practices such as home-based support for breastfeeding and other baby-friendly initiatives.
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Affiliation(s)
- Cheikh Mbacké Faye
- Research DivisionAfrican Population and Health Research CenterNairobiKenya,School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sharon Fonn
- School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
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Bakibinga P, Kamande E, Omuya M, Ziraba AK, Kyobutungi C. The role of a decision-support smartphone application in enhancing community health volunteers' effectiveness to improve maternal and newborn outcomes in Nairobi, Kenya: quasi-experimental research protocol. BMJ Open 2017; 7:e014896. [PMID: 28729309 PMCID: PMC5642658 DOI: 10.1136/bmjopen-2016-014896] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Improving maternal and newborn survival remains major aspirations for many countries in the Global South. Slum settlements, a result of rapid urbanisation in many developing countries including Kenya, exhibit high levels of maternal and neonatal mortality. There are limited referral mechanisms for sick neonates and their mothers from the community to healthcare facilities with ability to provide adequate care. In this study, we specifically plan to develop and assess the added value of having community health volunteers (CHVs) use smartphones to identify and track mothers and children in a bid to reduce pregnancy-related complications and newborn deaths in the urban slums of Kamukunji subcounty in Nairobi, Kenya. METHODS AND ANALYSIS This is a quasi-experimental study. We are implementing an innovative, mHealth application known as mobile Partnership for Maternal, Newborn and Child Health (mPAMANECH) which uses dynamic mobile phone and web-portal solutions to enable CHVs make timely decisions on the best course of action in their management of mothers and newborns at community level. The application is based on existing guidelines and protocols in use by CHVs. Currently, CHVs conduct weekly home visits and make decisions from memory or using unwieldy manual tools, and thus prone to making errors. mPAMANECH has an in-built algorithm that makes it easier, faster and more likely for CHVs to make the right management decision. We are working with a network of selected CHVs and maternity centres to pilot test the tool. To measure the impact of the intervention, baseline and end-line surveys will be conducted. Data will be obtained through qualitative and quantitative methods. ETHICS AND DISSEMINATION Ethical approval for the study was obtained from the African Medical Research Foundation. Key messages from the results will be packaged and disseminated through meetings, conference presentations, reports, fact sheets and academic publications to facilitate uptake by policy-makers.
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Affiliation(s)
- Pauline Bakibinga
- Health Challenges and Systems Research Program, African Population and Health Research Center, Nairobi, Kenya
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Lilford RJ, Oyebode O, Satterthwaite D, Melendez-Torres GJ, Chen YF, Mberu B, Watson SI, Sartori J, Ndugwa R, Caiaffa W, Haregu T, Capon A, Saith R, Ezeh A. Improving the health and welfare of people who live in slums. Lancet 2017; 389:559-570. [PMID: 27760702 DOI: 10.1016/s0140-6736(16)31848-7] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In the first paper in this Series we assessed theoretical and empirical evidence and concluded that the health of people living in slums is a function not only of poverty but of intimately shared physical and social environments. In this paper we extend the theory of so-called neighbourhood effects. Slums offer high returns on investment because beneficial effects are shared across many people in densely populated neighbourhoods. Neighbourhood effects also help explain how and why the benefits of interventions vary between slum and non-slum spaces and between slums. We build on this spatial concept of slums to argue that, in all low-income and-middle-income countries, census tracts should henceforth be designated slum or non-slum both to inform local policy and as the basis for research surveys that build on censuses. We argue that slum health should be promoted as a topic of enquiry alongside poverty and health.
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Affiliation(s)
- Richard J Lilford
- Warwick Centre for Applied Health Research and Delivery, University of Warwick, Coventry, UK.
| | - Oyinlola Oyebode
- Warwick Centre for Applied Health Research and Delivery, University of Warwick, Coventry, UK
| | | | - G J Melendez-Torres
- Warwick Centre for Applied Health Research and Delivery, University of Warwick, Coventry, UK
| | - Yen-Fu Chen
- Warwick Centre for Applied Health Research and Delivery, University of Warwick, Coventry, UK
| | - Blessing Mberu
- African Population and Health Research Centre, Manga Cl, Nairobi, Kenya
| | - Samuel I Watson
- Warwick Centre for Applied Health Research and Delivery, University of Warwick, Coventry, UK
| | - Jo Sartori
- Warwick Centre for Applied Health Research and Delivery, University of Warwick, Coventry, UK
| | - Robert Ndugwa
- Global Urban Observatory, Research and Capacity Development Branch, United Nations Human Settlements Programme, Nairobi, Kenya
| | - Waleska Caiaffa
- School of Medicine, Federal University of Minas Gerais, Brazil
| | - Tilahun Haregu
- African Population and Health Research Centre, Manga Cl, Nairobi, Kenya
| | | | - Ruhi Saith
- Oxford Policy Management, New Delhi, India
| | - Alex Ezeh
- African Population and Health Research Centre, Manga Cl, Nairobi, Kenya; School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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van de Vijver S, Oti S, Oduor C, Ezeh A, Lange J, Agyemang C, Kyobutungi C. Challenges of health programmes in slums. Lancet 2015; 386:2114-2116. [PMID: 26452707 DOI: 10.1016/s0140-6736(15)00385-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Steven van de Vijver
- African Population and Health Research Center, Nairobi, Kenya; Department of Global Health, Academic Medical Centre, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, Netherlands.
| | - Samuel Oti
- African Population and Health Research Center, Nairobi, Kenya; Department of Global Health, Academic Medical Centre, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, Netherlands
| | - Clement Oduor
- African Population and Health Research Center, Nairobi, Kenya
| | - Alex Ezeh
- African Population and Health Research Center, Nairobi, Kenya
| | - Joep Lange
- Department of Global Health, Academic Medical Centre, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, Netherlands
| | - Charles Agyemang
- Department of Public Health, Academic Medical Centre, University of Amsterdam, Netherlands
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