Socio-economic inequality and inequity in use of health care services in Kenya: evidence from the fourth Kenya household health expenditure and utilization survey

Enhancing Intersectoral Collaboration in Maternal Healthcare for the Realization of Universal Health Coverage in Kenya: The Perspectives of Health Facility Administrators in Kilifi County, Kenya

Intersectoral collaboration is an instrument that enables better productivity by filling in for possible gaps in knowledge, skills, and competencies in a given department by leveraging them from other departments. In Kenya, there is a paucity of information on intersectoral collaboration in healthcare. This article explores the possibilities of intersectoral collaboration, specifically in maternal healthcare, and what can be done to realize such collaborations to drive universal health coverage (UHC) in Kenya. Free maternity services (FMSs) are among the primary healthcare services that push Kenya towards UHC. In light of the centrality of UHC in driving current health policy, there are still several challenges which must be faced before this goal can be achieved. Moreover, competing priorities in health systems necessitate difficult choices regarding which health actions and investments to fund; these are complex, value-based, and highly political decisions. Therefore, the primary objective of this article is to explore health facility administrators' views on whether intersectoral collaboration could help with the realization of UHC in Kenya. The study area was Kilifi County, Kenya. The article is based on follow-up qualitative research conducted between March and July 2016 and from January to July 2017, and follow-up interviews conducted during COVID-19 in 2020 and 2021. The data are analyzed through a thematic analysis approach. The findings indicate that through Linda Mama, the expanded free maternity services program is one of the possible pathways to UHC. However, participants noted fair representation of stakeholders, distributed leadership, and local participation, considering bargaining power as a key issue that could enhance the realization of UHC in intersectoral collaboration through Linda Mama. These techniques require a bottom-up strategy to establish accountability, a sense of ownership, and trust, which are essential for UHC.

Regional economic level moderates the impact of patients' and family carers' cancer-related work changes and hospital level on financial toxicity in China: A multi-centre cross-sectional study

PURPOSE

To explore how regional economic levels moderate the relationships between cancer-related financial toxicity (FT) and its associated risk factors.

METHODS

A secondary analysis was conducted using data from a cross-sectional survey of 1208 adult patients with cancer, conducted in six tertiary and six secondary hospitals across three Chinese provinces from February to October 2022. The interactions between the regional economic level-categorised as high- or low-/middle-income based on the gross domestic product per capita- and 13 previously identified risk factors for FT were examined via moderation analysis using the PROCESS macro for SPSS software.

RESULTS

Regional economic level moderated the impacts of both patients' and family carers' negative work changes due to cancer and the hospital level on FT (all p-values for interaction effect <0.05). Job changes had more severe effects on FT in high-income regions (patients: B = -2.07, standard error [SE] = 0.67, p = 0.002; carers: B = -1.58, SE = 0.66, p = 0.017), while treatment in tertiary hospitals had a stronger negative impact on FT in low-/middle-income regions (B = 1.81, SE = 0.87, p = 0.037).

CONCLUSIONS

These findings highlight the need for region-specific FT mitigation strategies. In high-income regions, more attention could be paid to managing the adverse work-related effects of cancer on patients and their families. In low-/middle-income regions, increased awareness and management of cancer-related FT in tertiary hospitals is needed. Future research should explore other risk factors associated with FT that may be moderated by regional economic levels.

Determinants of treatment-seeking behaviour and healthcare provider choice in Afghanistan in 2018: a cross-sectional study

ABSTRACT

Introduction

In Afghanistan, remarkable achievements have been made in improving access to healthcare and health outcomes since the introduction of essential healthcare packages. Nonetheless, sociodemographic and geographical inequities persist, and out-of-pocket expenditures are high. This study investigates the client and provider determinants of access to care that affect treatment-seeking behaviour in 2018.

Methods

Secondary data analysis using data on treatment-seeking behaviour in public and private healthcare from the Afghanistan Health Survey 2018 was combined with data on the quality of public healthcare facilities from a national healthcare facility assessment of the same year. Logistic regression analyses were performed to explore associations between client characteristics and accessibility of public healthcare facilities, and treatment-seeking behaviour and choice of public versus private healthcare provider.

Results

The results suggest that the odds of seeking treatment are lowest among the rural poor. The odds of treatment-seeking and choosing a public healthcare provider are higher for pregnancy-related health needs but lower for chronic conditions. Affordability of healthcare was associated with lower odds of treatment-seeking (OR 0.96, 95% CI 0.95 to 0.98) and using private healthcare providers (OR 0.97, 95% CI 0.96 to 0.99). Increased satisfaction with opening hours (OR 1.04, 95% CI 1.02 to 1.05) and availability of a female nurse or doctor (OR 1.03, 95% CI 1.01 to 1.04) in public health facilities, and a higher level of trust in healthcare provider (OR 1.04, 95% CI 1.03 to 1.06) were associated with higher odds of using public healthcare.

Conclusion

Afghanistan's public healthcare system is vital in providing care to the economically disadvantaged and managing infectious diseases and maternal health problems. The private sector plays a dominant role, particularly for those illnesses not covered under the essential healthcare packages. The study suggests opportunities for the public healthcare system to alleviate financial barriers to healthcare access and broaden its service offerings to encompass the management of chronic illnesses.

Health-related quality of life of HIV patients with comorbidities of hypertension or diabetes in Ghana

Background

Clinical studies, particularly in the context of HIV/AIDS, have utilized health-related quality of life (HRQoL) and health state utility values to assess both clinical and economic implications. Improvement in HIV management with antiretroviral therapy (ART) has coincided with an increased morbidity of chronic conditions such as diabetes and hypertension among people living with HIV. The study offers empirical evidence establishing a link between HIV, comorbidities like hypertension and diabetes, and their collective impact on HRQoL.

Methods

A cross-sectional quantitative study among 418 HIV patients in three regions of Ghana in the Savannah, Middle Belt, and Coastal belt. Face-to-face interviews were conducted using EuroQol-5 Dimensions-5 Levels (EQ-5D-5L) in combination with EuroQol-Visual Analog Scales (EQ-VAS). Ugandan EQ-5D-5L value set was used for computing the utility values. Patients' socio-demographic and clinical data were obtained from medical records and analyzed descriptively. Mann-Whitney U and Kruskal Wallis tests were used to evaluate the relationship between patient socio-demographic and clinical variables and health status.

Results

Overall median utility value was 0.93(IQR=0.79, 1.00) from the EQ-5D index and 90 (IQR = 80, 100) from the EQ-VAS scores. Prevalence of hypertension and diabetes were 9.1% and 2.4% respectively. There was significant difference in EQ-VAS score between HIV patients with hypertension and those without hypertension (z = 2.146 p = 0.032). There was also a significant difference in the EQ-VAS scores (z = 2.381, p = 0.017) of patients with diabetes and those without diabetes. Region, sex, age, education, marital status, employment status, place of residence, monthly income level, duration of infection, adherence to ART, and other illness were significantly associated with EQ-5D-5L utility and EQ-VAS scores at 0.05 significant level.

Conclusion

HRQoL among HIV positive individuals in Ghana was high. Comorbidities such as hypertension or diabetes had nuanced effects on perceived health status. A patient-centered, multidisciplinary approach to HIV care should be adopted considering regional differences and the presence of comorbidities.

Factors associated with facility childbirth and skilled birth attendance in Migori County, Kenya and the effect of Lwala Community Alliance intervention: a cross-sectional assessment from the 2019 and 2021 Lwala household surveys

Background

Despite evidence of the beneficial effects of skilled birth attendance (SBA) on maternal health and childbirth outcomes, there are disparities in access across counties in Kenya. These include Migori County which has historically recorded high maternal mortality rates. In 2007, the Lwala Community Alliance was founded to improve health outcomes in this county. The objective of this study is to provide a baseline status of facility childbirth and SBA in Migori and to characterize the effect of Lwala intervention on these outcomes.

Methods

A cross-sectional household survey was designed for a 10-year study to evaluate the effectiveness of Lwala initiatives. The 2019 and 2021 household surveys were conducted in Lwala intervention wards and in comparison wards with sample sizes of 3,846 and 5,928 mothers, respectively. The survey captured demographic, health, and socioeconomic data at each household, data on SBA and facility childbirth, and explanatory variables. A generalized linear model was used to determine factors associated with SBA. A secondary trend analysis was conducted to determine change over time in the explanatory variables and SBA. To determine the change in SBA rate due to Lwala intervention, controlling for background temporal trends, a difference-in-differences (DiD) model compared SBA rates in intervention wards and comparison wards.

Results

SBA increased in all surveyed wards and across all explanatory variables from 2019 to 2021. The DiD analysis showed that the SBA rate increased more in Lwala intervention wards than in comparison wards (Adjusted Prevalence Rate Ratio 1.05, p < 0.001, 95%CI 1.03-1.08). The 2021 survey found the highest rates of both facility childbirths (97.9%, 95%CI 96.5-98.7) and SBA (98.2%, 95%CI 97.0-99.0) in North Kamagambo, the oldest ward of Lwala intervention. Higher educational status, four or more ANC visits, marriage/cohabitation, and wealth were significantly associated with increased SBA.

Conclusions

We provide the first quasi-experimental evidence that Lwala interventions are significantly improving SBA which may inform related initiatives in similar settings. The household-survey data provides a baseline for continued evaluation of Lwala programs, and the breakdown by ward allows for development of specific programmatic targets.

Wealth disparities in maternal health service utilization among women of reproductive age in Ethiopia: findings from the mini-EDHS 2019

BACKGROUND

Ethiopia has made strides in reducing maternal mortality, but significant discrepancies in maternal health service utilization exist across socioeconomic levels. According to studies, women from higher-income households are far more likely to use essential services such as antenatal care, delivery care, and postnatal care than poorer women. This wealth disparity is a primary contributor to persistently high maternal mortality, particularly among poor populations. The study's goal was to assess wealth disparities in maternal health service uptake and identify contributing factors.

METHODS AND MATERIALS

We used the Ethiopian Mini Demographic Health Survey (EMDHS), conducted in 2019 on women aged 15-49 living in selected census areas, with a weighted sample size of 3,909. The Erreygers Concentration Index (ECI) was used to measure wealth inequalities in maternal health care, and the ECI decomposition was used to identify factors contributing to inequality in maternal health services.

RESULTS

Maternal health service utilization was pro-rich among women in Ethiopia. The prevalence of antenatal care service (ANC), delivery, and postnatal care (PNC) service utilization showed a pro-rich distribution among Ethiopian women, with ECI = 0.115 (95% CI: 0.091-0.137), ECI = 0.223 (95% CI: 0.191-0.276), and ECI = 0.121 (95% CI: 0.041-0.200), respectively. The ECI indices were decomposed to examine the contributing factors to disparities in maternal service utilization in Ethiopia. Mother's current age, household family size, region, birth order, and parity were contributors to maternal health service utilization.

CONCLUSION

The ANC service, delivery service and PNC service utilization showed a pro-rich distribution among Ethiopian women. Mother's current age, household family size, region, birth order, and parity are important contributors of maternal health service inequality. To improve access and usage among low-income women, policymakers can develop programs including increasing the number of free or subsidized services and providing transportation.

Decomposing socioeconomic inequality in household out of pocket health expenditures in Pakistan (2010-11-2018-19)

BACKGROUND

The increased socioeconomic inequality in catastrophic health expenditure (CHE) disproportionately affects disadvantaged populations, subjecting them to financial hardships, limiting their access to healthcare, and exacerbating their vulnerability to morbidity.

OBJECTIVES

This study examines changes in socioeconomic inequality related to CHE and analyzes the contributing factors responsible for these changes in Pakistan between 2010-11 and 2018-19.

METHODS

This paper extracted the data on out-of-pocket health expenditures from the National Health Accounts for 2009-10 and 2017-18. Sociodemographic information was gathered from the Household Integrated Economic Surveys of 2010-11 and 2018-19. CHE was calculated using budget share and the ability-to-pay approaches. To assess socioeconomic inequality in CHE in 2010-11 and 2018-19, both generalized and standard concentration indices were used, and Wagstaff inequality decomposition analysis was employed to explore the causes of socioeconomic inequality in each year. Further, an Oaxaca-type decomposition was applied to assess changes in socioeconomic inequality in CHE over time.

RESULTS

The concentration index reveals that socioeconomic inequality in CHE decreased in 2018-19 compared to 2010-11 in Pakistan. Despite the reduction in inequality, CHE was concentrated among the poor in Pakistan in 2010-11 and 2018-19. The inequality decomposition analysis revealed that wealth status was the main cause of inequality in CHE over time. The upper wealth quantiles indicated a positive contribution, whereas lower quantiles showed a negative contribution to inequality in CHE. Furthermore, urban residence contributed to pro-rich inequality, whereas employed household heads, private healthcare provider, and inpatient healthcare utilization contributed to pro-poor inequality. A noticeable decline in socioeconomic inequality in CHE was observed between 2010 and 2018. However, inequality remained predominantly concentrated among the lower socio-economic strata.

CONCLUSION

These results underscore the need to improve the outreach of subsidized healthcare and expand social safety nets.

Sociodemographic disparities in postnatal care coverage at comprehensive health centers in Hamedan City

Background

Postnatal care (PNC) is a crucial component of continuous healthcare and can be influenced by sociodemographic factors. This study aimed to examine the sociodemographic disparities in PNC coverage in Hamedan City.

Methods

In this cross-sectional study, we utilized existing data recorded in the Health Integrated System of Hamedan City, located in Iran, from 2020 to 2021. The study population consisted of 853 women who were over 15 years old and had given birth within the past 42 days. The Health Equity Assessment Toolkit (HEAT) software was used to evaluate the socioeconomic inequalities in PNC coverage.

Results

Overall, 531 (62.3%) of the women received three postnatal visits. The absolute concentration index (ACI) indicates that women aged 20-35 years, illiterate women, housewives, insured individuals, and urban residents experience a higher magnitude of inequality in PNC coverage. The negative values of the ACI suggest that the health index is concentrated among disadvantaged groups, with educational level inequalities being more pronounced than those related to age.

Conclusion

Postnatal care coverage among mothers was relatively adequate; however, sociodemographic inequalities existed in the utilization of PNC services. It is recommended that policymakers make efforts to increase access to PNC services for mothers from low socio-economic groups.

An Examination of Inter-State Variation in Utilization of Healthcare Services, Associated Financial Burden and Inequality: Evidence from Nationally Representative Survey in India

This study examines the health care utilization pattern, associated financial catastrophes, and inequality across Indian states to understand the subnational variations and aid the policy makers in this regard. Data from recent National Sample Survey (2017-2018), titled, "Household Social Consumption: Health," covering 113,823 households, was employed in the study. Descriptive statistics, Erreygers concentration index (CI), and recentered influence function decomposition were applied in the study. We found that, in India, 7 percent of households experienced catastrophic health expenditure (CHE) and 1.9 percent of households were pushed below poverty line due to out-of-pocket expenditure on hospitalization. Notably, outpatient care was more burdensome (CHE: 12.1%; impoverishment: 4%). Substantial interstate variations were observed, with high financial burden in poorer states. Utilization of health care services from private health care providers was pro-rich (hospitalization CI 0.31; outpatient CI 0.10), while the occurrence of CHE incidence was pro-poor (hospitalization CI -0.10; outpatient CI -0.14). Education level, economic status, health insurance, and area of residence contributed significantly to inequalities in utilization of health care services from private providers and financial burden. The high financial burden of seeking health care necessitates the need to increase public health spending and strengthen public health infrastructure. Also, concerted efforts directed towards increasing awareness about health insurance and introducing comprehensive health insurance products (covering both inpatient and outpatient services) are imperative to augment financial risk protection in India.

Routine data in a primary care performance dashboard, Ethiopia

Objective

To explore the feasibility of building a primary care performance dashboard using DHIS2 data from Ethiopia's largest urban (Addis Ababa), agrarian (Oromia) and pastoral (Somali) regions.

Methods

We extracted 26 data elements reported by 12 062 health facilities to DHIS2 for the period 1 July 2022 to 30 June 2023. Focusing on indicators of effectiveness, safety and user experience, we built 14 indicators of primary care performance covering reproductive, maternal and child health, human immunodeficiency virus, tuberculosis, noncommunicable disease care and antibiotic prescription. We assessed data completeness by calculating the proportion of facilities reporting each month, and examined the presence of extreme outliers and assessed external validity.

Findings

At the regional level, average completeness across all data elements was highest in Addis Ababa (82.9%), followed by Oromia (66.2%) and Somali (52.6%). Private clinics across regions had low completeness, ranging from 38.6% in Somali to 58.7% in Addis Ababa. We found only a few outliers (334 of 816 578 observations) and noted that external validity was high for 11 of 14 indicators of primary care performance. However, the 12-month antiretroviral treatment retention rate and proportions of patients with controlled diabetes or hypertension exhibited poor external validity.

Conclusion

The Ethiopian DHIS2 contains information for measuring primary care performance, using simple analytical methods, at national and regional levels and by facility type. Despite remaining data quality issues, the health management information system is an important data source for generating health system performance assessment measures on a national scale.

Assessing patient satisfaction among COVID-19 survivors in Northeast India: a cross-sectional study

Introduction

This study investigates patient satisfaction among COVID-19 survivors in Northeast India, motivated by the unique long-term healthcare needs of survivors and the critical role of patient satisfaction in assessing and enhancing healthcare quality. By focusing on this underexplored region, the research aims to uncover insights that can guide improvements in patient-centered care and healthcare service delivery in similar contexts.

Materials and methods

The study was conducted using a Simple Random Sampling technique. Data were collected through telephone interviews using a semi-structured questionnaire, including the Patient Satisfaction Questionnaire-18 (PSQ-18) for analysis. The PSQ-18 yielded seven subscale scores representing different dimensions of patient satisfaction. Statistical analysis using SPSS software was conducted to summarize socio-demographic characteristics, medical history, and patient satisfaction levels, employing both descriptive and inferential statistics.

Result

The results indicated a high acceptance of COVID-19 vaccination, with the majority of participants having received both doses. Patient satisfaction with healthcare services is generally positive, particularly in aspects related to doctor-patient communication and medical care quality. However, there are notable concerns regarding the affordability and timeliness of care. Regional variations across states, as well as factors like education and income, significantly influence patient satisfaction levels.

Conclusion

The study revealed generally good patient satisfaction levels in Northeast India. However, challenges in healthcare affordability and timeliness persist, influenced by regional disparities and socio-economic factors. Targeted interventions are needed to improve healthcare in the region.

Healthcare cost coverage inequality and its impact on hypertension and diabetes: A five-year follow-up study in a Malaysian rural community

Background and Aims

Inequality in health care access is a socioeconomic driver for non-communicable disease related risk factors. This study examined the inequality trend in healthcare cost coverage (HCC) compared to private health insurance (PHI) coverage, a subtype of HCC, over 5 years. The study will also determine the association between HCC (and PHI) and the status of hypertension and diabetes diagnosis.

Method

The rich-poor ratio, concentration curve and concentration index were derived to determine the level of inequality. Furthermore, logistic regression was done to determine the association between HCC and the status of hypertension and diabetes.

Results

The PHI group (rich-poor ratio: 1.4 [rich: 454, poor: 314] and 2.6 [rich: 375, poor: 142]; concentration index: 0.123 [95% confidence interval, CI: 0.093-0.153] and 0.144 [95% CI: 0.109-0.178] in 2013 and 2018, respectively) has relatively higher inequality compared with the HCC group (rich-poor ratio: 0.9 [rich: 307, poor: 337] and 1.1 [rich: 511, poor: 475]; concentration index: -0.027 [95% CI: -0.053 to -0.000] and -0.014 [95% CI: -0.033 to 0.006] in 2013 and 2018, receptively). Contrasting to the observation with the HCC group, PHI was associated with higher odds for hypertension (adjusted odds ratio [aOR] = 1.252, p = 0.01, 95% CI: 1.051-1.493) and diabetes (aOR = 1.287, p = 0.02, 95% CI: 1.041-1.590) in 2018.

Conclusion

Over 5 years, the inequality in PHI coverage remained higher compared with HCC, which suggests that the rich enjoyed private healthcare more. Furthermore, those with PHI were more likely to report known hypertension and diabetes in 2018. It is reasonable to assume that those with PHI are more likely to have earlier diagnoses compared to others and are more likely to be aware of their condition. Policymakers need to identify strategies that can narrow the existing gap in quality and type of service between the private and public health sectors.

Socioeconomic inequalities in the use of medical consultation services in Peru, 2019

BACKGROUND

Socioeconomic inequalities in the population influence access to health services and constitute a challenge for health systems, especially in low- and middle-income countries. In Peru, an increase in the use of medical services has been estimated; however, the study of inequalities in the use of medical services is limited. Therefore, the objective of this research was to analyze and decompose socioeconomic inequalities in the use of medical consultation services in Peru.

METHODS

A cross-sectional analytical study was conducted using data from the National Household Survey 2019. The outcome variable was the use of a consultation attended by a physician in the last 4 weeks in persons who presented symptom or discomfort, illness, relapse of chronic disease and/or accident. Concentration curves and Erreygers concentration indices were used to determine socioeconomic inequalities, and a generalized linear regression model was used for the decomposition analysis of inequalities.

RESULTS

A total of 52,715 persons were included in the study. The frequency of medical consultation was 25.4% (95% confidence interval: 24.8 - 26.1%). In the inequality analysis, it was found that the use of medical consultations was concentrated among the wealthiest individuals. The main contributing factors were having another type of health insurance (social health insurance [EsSalud], private health insurance, health provider, the Armed Forces, and the Police), residing in an urban area, belonging to the richest wealth quintile, having a chronic disease, and residing in the highlands of Peru.

CONCLUSIONS

Based on our findings, government institutions seeking to achieve equitable access to health services should consider the main factors contributing to this inequality in the formulation of strategies to lessen the negative impact of inadequate disease control in the population.

Decomposition of Healthcare Utilization Inequality in Iran: The Prominent Role of Health Literacy and Neighborhood Characteristics

Unequal utilization in healthcare can potentially affect the right to health. Access to healthcare services and achieving positive health outcomes and health equity are essential principles in promoting human rights. This study aims to assess and analyze socioeconomic-related inequalities in outpatient health services utilization (OHSU) among various socio-demographic subgroups to inform policies that foster health equity. Data were collected through a cross-sectional survey of 1200 households in Tehran, Iran. Inequality in OHSU among the socio-demographic subgroups was calculated by concentration, Wagstaff, and Erigers indices. Decomposition was used to identify the factors contributing to inequality in OHSU. Marginal effect and elasticity were used to calculate the relative absolute shares of socio-demographic variables in the inequality. The rate of OHSU was 63.61% (CI: 60-66.80) which concentrated among households with better socioeconomic status. Based on the results, living in an affluent neighborhood (Relative share (RS): 85.48) and having a disabled member in the household (RS: 6.58) were the most important factors in the concentration of OHSU in favor of the privileged groups. In contrast, very low levels of health knowledge (RS: -83.79) and having basic insurance coverage (RS: -3.92) concentrated OHSU in favor of the lower socioeconomic households. The study was conducted based on survey data, and this may lead to some limitations. Given that this study was a cross-sectional study, we were unable to establish causal relationships between explanatory variables and outpatient health service utilization and its relevant predictors. Households with disabled member(s), as well as a member(s) with chronic diseases, may experience severe inequalities in access to healthcare services. Policies that facilitate access to health services for these households can play a significant role in improving health equity.

Socioeconomic inequality and contributors in accepting attitudes toward people living with HIV among adults in Ethiopia from 2005 to 2016: a population-based cross-sectional study

INTRODUCTION

The public's accepting attitude toward people living with HIV is crucial in reducing HIV-related stigma and discrimination, increasing people's access to HIV service. This study examines the inequalities in accepting attitudes toward people living with HIV in Ethiopia from 2005 to 2016.

METHODS

This cross-sectional study was based on the 2005, 2011 and 2016 Ethiopian Demographic Health Surveys. A total of 17 075, 28 478 and 25 542 adults were included in the 2005, 2011 and 2016 surveys, respectively. Socioeconomic inequality was investigated using the concentration curve and Erreygers' concentration index (ECI), which is scaled from -1 (pro-poor) to +1 (pro-rich). The ECI was decomposed to identify the contributors to socioeconomic inequality using generalised linear regression with the logit link function.

RESULTS

Accepting attitude toward people living with HIV was 17.9% (95% CI: 16.6%, 19.3%) in 2005, which increased to 33.5% (95% CI: 31.8%, 35.3%) in 2011 and 39.6% (95% CI: 37.6%, 41.9%) in 2016. ECI was 0.342 (p<0.001), 0.436 (p<0.001) and 0.388 (p<0.001), respectively, for 2005, 2011 and 2016. The trend line illustrates socioeconomic inequality seems diverging over time, with an increasing ECI of 0.005 every year (r=0.53; p=0.642; slope=0.005).

CONCLUSIONS

The current study found that there was pro-rich inequality from 2005 to 2016. People with higher socioeconomic status had a better attitude toward people living with HIV. Comprehensive knowledge about HIV/AIDS, education status, residence, and access to electronic and paper-based media, as well as HIV testing, contribute to a better accepting attitude toward people living with HIV. It is of utmost importance for the country to enhance accepting attitude toward people living with HIV to reduce stigma and discrimination. This requires whole-system response according to the primary healthcare approach toward ending the epidemic of HIV/AIDS in the country.

Self-Reported Hypertension and Associated Factors Among Adults in Butambala District, Central Uganda: A Community-Based Prevalence Study

Background

The prevalence of hypertension (HTN) differs among regions and income groups, showing a substantial increase in low- and middle-income countries. The development of hypertension is modulated by modifiable lifestyle factors, and uncontrolled hypertension poses a risk for the onset of cardiovascular diseases.

Objective

To determine the community-level point-prevalence and factors associated with self-reported HTN among adults in Butambala district, central Uganda.

Methods

A community-based cross-sectional study was conducted among adults aged ≥18 years in Budde subcounty, central Uganda. Data on sociodemographic characteristics and behavior were collected using a semistructured questionnaire. Self-reported HTN was assessed using a single question: "Do you have high blood pressure?" Bivariate and multivariate logistic regression analyses were performed to identify predictors of self-reported HTN.

Results

A total of 565 participants (53.5% female) with a median age of 38 years (IQR: 26-52) were included in the study. The prevalence of self-reported hypertension was 18.9%. Factors independently associated with HTN were age 60 years or older (aOR: 2.9, 95% CI: 1.64-5.23, p<0.001), female sex (aOR: 3.3, 95% CI: 2.3-6.3, p<0.001), being widowed (aOR: 10.4, 95% CI: 1.25-87.14, p=0.03), secondary (aOR: 0.4, 95% CI: 0.20-0.85, p=0.016) and tertiary (aOR: 0.2, 95% CI: 0.09-0.64, p=0.005) education, unemployment (aOR: 3.0, 95% CI: 1.11-7.96, p=0.03), tobacco use (aOR: 2.9, 95% CI: 1.83-4.53, p<0.001), having had at least one blood pressure measurement during antenatal visit (aOR: 4.7, 95% CI: 1.97-11.33, p<0.001) or medical checkup (aOR: 10.7, 95% CI: 6.06-18.

Conclusion

We observed a high prevalence of self-reported HTN affecting approximately one in five participants. More efforts are required to enhance routine screening, health education, and accessibility to HTN services in rural areas, with a particular emphasis on implementing HTN prevention and control strategies to effectively reduce the prevalence of HTN.

Can a private sector engagement intervention that prioritizes pro-poor strategies improve healthcare access and quality? A randomized field experiment in Kenya

Private sector engagement in health reform has been suggested to help reduce healthcare inequities in sub-Saharan Africa, where populations with the most need seek the least care. We study the effects of African Health Markets for Equity (AHME), a cluster randomized controlled trial carried out in Kenya from 2012 to 2020 at 199 private health clinics. AHME included four clinic-level interventions: social health insurance, social franchising, SafeCare quality-of-care certification programme and business support. This paper evaluates whether AHME increased the capacity of private health clinics to serve poor clients while maintaining or enhancing the quality of care provided. At endline, clinics that received AHME were 14.5 percentage points (pp) more likely to be empanelled with the National Health Insurance Fund (NHIF), served 51% more NHIF clients and served more clients from the middle three quintiles of the wealth distribution compared to control clinics. Comparing individuals living in households near AHME treatment and control clinics (N = 8241), AHME led to a 6.7-pp increase in the probability of holding any health insurance on average. We did not find any additional effect of AHME on insurance holding among poor households. We measured quality of care using a standardized patient (SP) experiment (N = 596 SP-provider interactions) where recruited and trained SPs were randomized to present as either 'not poor', and able to afford all services provided, or 'poor' by telling the provider they could only afford ∼300 Kenyan Shillings (US$3) in fees. We found that poor SPs received lower levels of both correct and unnecessary services, and AHME did not affect this. More work must be done to ensure that clients of all wealth levels receive high-quality care.

Impact of the presence of private hospitals on the spatial equality of healthcare accessibility in Beijing, China

Providing equal geographical access to hospitals, either in the public or private healthcare sector, is vital and will benefit public health in general. Against the background of the partial privatization of the healthcare sector, the impact of private hospitals on equal healthcare access has been a highly neglected issue. We have applied an assessment methodology to study this situation by comparing the status quo scenario with one without private hospitals, based on accessibility analysis and spatial equality measurements. The case study of Beijing, China revealed a double-sided impact. With the presence of private hospitals, the Gini coefficient of spatial accessibility in urban districts was reduced from 0.03391 to 0.03211, while it increased from 0.1734 to 0.1914 in suburban districts. Thus, private hospitals improved spatial equality in urban districts in Beijing but jeopardized it in suburban districts. These research findings should enlighten policymakers to promote healthcare equality but would also need to be repeated in some other big cities.

Inequity in the healthcare utilization among latent classes of elderly people with chronic diseases and decomposition analysis in China

BACKGROUND

Studies have shown chronic disease-based healthcare utilization inequity is common. Hence, exploring this issue can help in establishing targeted measures and protecting the rights and interests of vulnerable groups. Against this background, the purpose of this study is to explore the latent classification of elderly patients with chronic disease and compare healthcare utilization inequity among latent classes.

METHODS

This study used the data of 7243 elderly patient with chronic diseases collected from the China Health and Retirement Longitudinal Study in 2018. Latent class analysis was used to classify the patients with chronic diseases, and analysis of variance and [Formula: see text] tests were utilized to test the differences in characteristics among latent classes. Healthcare utilization inequity was measured based on the concentration index (CI), and the CI was decomposed to compare the horizontal index of healthcare utilization among the latent classes.

RESULTS

The patients with chronic diseases were divided into five latent classes, namely, the musculoskeletal system, hypertension, respiratory system, digestive system and cardiovascular system groups. Statistically significant differences in social demographic characteristics were observed among the five latent classes (P < 0.05). A pro-rich healthcare utilization inequity for all respondents was observed (outpatient CI = 0.080, inpatient CI = 0.135), and a similar phenomenon in latent classes was found except for the musculoskeletal system group in outpatient visits (CI = -0.037). The digestive system group had the worst equity (outpatient CI = 0.197, inpatient CI = 0.157) and the respiratory system group had the best (outpatient CI = 0.001, inpatient CI = 0.086). After balancing the influence of health need factors, healthcare utilization inequity was almost alleviated. Furthermore, for all respondents, the contribution of health need factors (65.227% for outpatient and 81.593% for inpatient) was larger than that of socioeconomic factors (-21.774% for outpatient and 23.707 for inpatient), and self-rated health status was the greatest contributor (57.167% for outpatient and 79.399% for inpatient). The characteristics were shown in latent classes.

CONCLUSIONS

Healthcare utilization inequity still exists in elderly patients with chronic diseases, and the specific performances of inequity vary among latent classes. Moreover, self-rated health status plays an important role in healthcare utilization inequity. Providing financial support to low-income patients with certain chronic diseases, focusing on their physical and mental feelings and guiding them to evaluate their health status correctly could be essential for alleviating healthcare utilization inequity among elderly patients with chronic diseases.

How to Make Primary Healthcare More Popular: Evidence from the Middle-Aged and Elderly in China

Since 2001, China has been an aging society; it is expected to become superaged by 2033. This rapid aging trend poses a challenge to the elderly regarding their pension services and healthcare. Primary healthcare has great potential for serving older adults in the community, yet it is not popular. This study used 1977 samples from the 2018 China Health and Retirement Longitudinal Study database to explore the use of outpatient services in primary care institutions among the middle-aged and elderly. Using a structural equations model, we constructed a framework to explore pathways leading to primary outpatient use. We discovered that the supply of primary health services had a significant direct and mediating effect on the utilization of primary outpatient services, and that community pension services may indirectly discourage it. In addition, the supply of primary health services has a suppressor effect between medical insurance and primary outpatient utilization. Health insurance directly promotes primary outpatient utilization, while the supply of primary care institutions suppresses the positive influence of medical insurance on the utilization of primary outpatient services. Therefore, community pension services should pay attention to differentiated services. Moreover, adjusting the coordinated development of medical insurance and the supply of primary healthcare could enhance the positive effects of medical insurance for outpatients.

The healthcare inequality among middle-aged and older adults in China: a comparative analysis between the full samples and the homogeneous population

BACKGROUND

In the Chinese population, the middle-aged and older adults are the two main segments that utilize a large portion of healthcare. With the fast growth of the two segments, the demands of healthcare services increases significantly. The issue related to inequality in utilization of healthcare emerges with the growth and it deserves more attention. Most existing studies discuss overall inequality. Less attention is paid to inequality among subdivisions, that is, relative inequality. This study focuses on the inequality of healthcare utilization among the homogeneous population and the inequality of the full samples in China.

METHODS

Data were obtained from four waves of the China Health and Retirement Longitudinal Study (CHARLS): 2011, 2013, 2015 and 2018. First, the Concentration Index (CI) was used to measure the inequality of outpatient, inpatient and preventive care for the samples, and regression analysis was applied to decompose the contributing factors of inequality. Then SOM is introduced to identify homogeneous population through clustering and measure the inequality in three types of healthcare utilization among homogeneous population. Based on this, the difference between absolute inequalities and relative inequalities was discussed.

RESULTS

The preventive care is shown to have the highest degree of inequality inclined to the rich and has the largest increase (CI: 0.048 in 2011 ~ 0.086 in 2018); The inequality degree in outpatient care appears to be the smallest (CI: -0.028 in 2011 ~ 0.014 in 2018). The decomposition results show that age, education, income, chronic disease and self-reported health issues help explain a large portion of inequality in outpatient and inpatient care. And the contribution of socioeconomic factors and education to the inequality of preventive care is the largest. In regards to three types of healthcare among the homogeneous population, the degree of inequality seems to be higher among group with high socioeconomic status than those with lower socioeconomic status. In particular, for the people who are in the high socioeconomic group, the degree of inequality in preventive care is consistently higher than in outpatient and inpatient care. The inequality degree of preventive care in the low socioeconomic status group varies significantly with the flexibility of their response to policies.

CONCLUSIONS

Key policy recommendations include establishing a health examination card and continuously improving the fit of free preventive care with the needs of the middle-aged and older adults; developing CCB activities to avoid people's excessive utilization in the high socioeconomic status group or insufficient utilization in the low socioeconomic status group; reasonable control of reimbursement and out-of-pocket payments.

The critical need for WASH in emergency preparedness in health settings, the case of COVID-19 pandemic in Kisumu Kenya

The devastating effects of inadequate basic utilities such as water, sanitation, hygiene, waste management and environmental cleaning (WASH) is underscored by the current global pandemic declared on March 11, 2020. This paper explores the experiences of key informants (n = 15) ie government and non-government organization officials on the impacts of the COVID-19 pandemic in health care facilities (HCFs) and the role of WASH in emergency preparedness in health settings and the communities they serve using Kisumu, Kenya as a case study. The results from interviews with the key informants indicate socioecological challenges shaping access to hygiene services in HCFs and related disparities in social determinants of health such as WASH that serve as barriers to the pandemic response. All participants indicated the healthcare system was ill-prepared for the pandemic. Health care workers experienced such severe psychosocial impacts due to the lack of preparedness that they subsequently embarked on strikes in protest. These situations influenced citizens' perceptions of the COVID-19 pandemic as a hoax and resulted in a surge in other population health indicators (e.g., increased maternal mortality; decreased vaccination rates for other illnesses such as measles). We recommend authentic partnerships among all stakeholders to develop and implement context-driven sustainable solutions that integrate WASH and emergency preparedness in HCFs and the communities they serve across all spatial scales, from the global to the local.

Inequity in Health Services Utilization in Economically Underdeveloped Regions of Northeast China

Background

The Chinese health system has long been committed to eliminating inequalities in health services utilization. However, few studies have analyzed or measured these inequalities in economically underdeveloped regions in China.

Methods

A total of 6,627 respondents from 3,000 households in Heilongjiang Province were extracted from the Sixth National Health Services Survey. We measured horizontal inequity in both 2-week outpatient rate and annual inpatient rate, and then identified the factors contributing to inequality.

Results

The horizontal inequity indices of the 2-week outpatient and annual impatient rates in Heilongjiang Province were 0.0586 and 0.1276, respectively. Household income, health status, place of residence, basic medical insurance, and commercial health insurance were found to be the main factors affecting inequality in health services utilization. The contributions of household income to these two indices were 184.03 and 253.47%, respectively. Health status factors, including suffering from chronic disease, limitations in daily activities, and poor self-rated health, played positive roles in reducing inequality in these two indices. The contributions of place of residence to these two indices were 27.21 and −28.45%, respectively. Urban Employee Basic Medical Insurance made a pro-rich contribution to these two indices: 56.25 and 81.48%, respectively. Urban and Rural Resident Basic Medical Insurance, Urban Resident Basic Medical Insurance, New Rural Cooperative Medical Scheme, and other basic medical insurance made a pro-poor contribution to these two indices: −73.51 and −54.87%, respectively. Commercial health insurance made a pro-rich contribution to these two indices: 20.79 and 7.40%, respectively. Meanwhile, critical illness insurance made a slightly pro-poor contribution to these two indices: −4.60 and −0.90%, respectively.

Conclusions

The findings showed that the “equal treatment in equal need” principle was not met in the health services utilization context in Heilongjiang Province. To address this issue, the government could make policy changes to protect low-income populations from underused health services, and work to improve basic medical insurance, critical illness insurance, and social security systems.

Socioeconomic Inequity in the Screening and Treatment of Hypertension in Kenya: Evidence From a National Survey

Background

Non-communicable diseases (NCDs) account for 50% of hospitalisations and 55% of inpatient deaths in Kenya. Hypertension is one of the major NCDs in Kenya. Equitable access and utilisation of screening and treatment interventions are critical for reducing the burden of hypertension. This study assessed horizontal equity (equal treatment for equal need) in the screening and treatment for hypertension. It also decomposed socioeconomic inequalities in care use in Kenya.

Methods

Cross-sectional data from the 2015 NCDs risk factors STEPwise survey, covering 4,500 adults aged 18-69 years were analysed. Socioeconomic inequality was assessed using concentration curves and concentration indices (CI), and inequity by the horizontal inequity (HI) index. A positive (negative) CI or HI value suggests a pro-rich (pro-poor) inequality or inequity. Socioeconomic inequality in screening and treatment for hypertension was decomposed into contributions of need [age, sex, and body mass index (BMI)] and non-need (wealth status, education, exposure to media, employment, and area of residence) factors using a standard decomposition method.

Results

The need for hypertension screening was higher among poorer than wealthier socioeconomic groups (CI = -0.077; p < 0.05). However, wealthier groups needed hypertension treatment more than poorer groups (CI = 0.293; p <0.001). Inequity in the use of hypertension screening (HI = 0.185; p < 0.001) and treatment (HI = 0.095; p < 0.001) were significantly pro-rich. Need factors such as sex and BMI were the largest contributors to inequalities in the use of screening services. By contrast, non-need factors like the area of residence, wealth, and employment status mainly contributed to inequalities in the utilisation of treatment services.

Conclusion

Among other things, the use of hypertension screening and treatment services in Kenya should be according to need to realise the Sustainable Development Goals for NCDs. Specifically, efforts to attain equity in healthcare use for hypertension services should be multi-sectoral and focused on crucial inequity drivers such as regional disparities in care use, poverty and educational attainment. Also, concerted awareness campaigns are needed to increase the uptake of screening services for hypertension.

What Drives Outpatient Care Costs in Kenya? An Analysis With Generalized Estimating Equations

Objective: This study aimed to identify the factors associated with outpatient expenses incurred by households in Kenya.

Background: The problem of outpatient healthcare expenses incurred by citizens in countries with limited resources has received little attention. Thus, this study aimed to determine the predictors of household spending on outpatient expenses in Kenya.

Method: We conducted a cross-sectional analysis on households in Kenya using data from the 2018 Kenya Household Health Expenditure and Utilization Survey. We applied the generalized estimating equations method to determine the best subset of predictors of outpatient care cost.

Findings: The best predictors of outpatient care expenses in Kenya are age, wealth index, and education level of the household head.

Conclusions: There were no differences regarding age in the mean spending on outpatient care. Moreover, we found that the cost of outpatient care changes with age in a sinusoidal manner. We observed that rich households spent more on outpatient care, mostly owing to their financial ability. Households whose heads reported primary or secondary school education level spent less on outpatient costs than households headed by those who never went to school.

Impact of household shocks on access to healthcare services in Kenya: a propensity score matching analysis

OBJECTIVE

This study examines the effects of household shocks on access to healthcare services in Kenya. Shocks are adverse events that lead to loss of household income and/or assets.

DESIGN AND SETTING

The study used data from the Kenya Integrated Household Budget Survey 2015/2016, a nationally representative cross-sectional survey. A propensity score matching approach was applied for the analysis.

PARTICIPANTS

The study sample included 16 297 individuals from households that had experienced shocks (intervention) and those that had not experienced shocks (control) within the last 12 months preceding the survey.

OUTCOME MEASURES

The outcome of interest was access to healthcare services based on an individual's perceived need for health intervention.

RESULTS

The results indicate that shocks reduce access to healthcare services when household members are confronted with an illness. We observed that multiple shocks in a household exacerbate the risk of not accessing healthcare services. Asset shocks had a significant negative effect on access to healthcare services, whereas the effect of income shocks was not statistically significant. This is presumably due to the smoothing out of income shocks through the sale of assets or borrowing. However, considering the time when the shock occurred, we observed mixed results that varied according to the type of shock.

CONCLUSIONS

The findings suggest that shocks can limit the capacity of households to invest in healthcare services, emphasising their vulnerability to risks and inability to cope with the consequences. These results provoke a debate on the causal pathway of household economic shocks and health-seeking behaviour. The results suggest a need for social protection programmes to integrate mechanisms that enable households to build resilience to shocks. A more viable approach would be to expedite universal health insurance to cushion households from forgoing needed healthcare when confronted with unanticipated risks.

'It was hell in the community': a qualitative study of maternal and child health care during health care worker strikes in Kenya

BACKGROUND

Health care workers in Kenya have launched major strikes in the public health sector in the past decade but the impact of strikes on health systems is under-explored. We conducted a qualitative study to investigate maternal and child health care and services during nationwide strikes by health care workers in 2017 from the perspective of pregnant women, community health volunteers (CHVs), and health facility managers.

METHODS

We conducted in-depth interviews and focus group discussions (FGDs) with three populations: women who were pregnant in 2017, CHVs, and health facility managers. Women who were pregnant in 2017 were part of a previous study. All participants were recruited using convenience sampling from a single County in western Kenya. Interviews and FGDs were conducted in English or Kiswahili using semi-structured guides that probed women's pregnancy experiences and maternal and child health services in 2017. Interviews and FGDs were audio-recorded, translated, and transcribed. Content analysis followed a thematic framework approach using deductive and inductive approaches.

RESULTS

Forty-three women and 22 CHVs participated in 4 FGDs and 3 FGDs, respectively, and 8 health facility managers participated in interviews. CHVs and health facility managers were majority female (80%). Participants reported that strikes by health care workers significantly impacted the availability and quality of maternal and child health services in 2017 and had indirect economic effects due to households paying for services in the private sector. Participants felt it was the poor, particularly poor women, who were most affected since they were more likely to rely on public services, while CHVs highlighted their own poor working conditions in response to strikes by physicians and nurses. Strikes strained relationships and trust between communities and the health system that were identified as essential to maternal and child health care.

CONCLUSION

We found that the impacts of strikes by health care workers in 2017 extended beyond negative health and economic effects and exacerbated fundamental inequities in the health system. While this study was conducted in one County, our findings suggest several potential avenues for strengthening maternal and child health care in Kenya that were highlighted by nationwide strikes in 2017.

Mapping socioeconomic inequalities in malaria in Sub-Sahara African countries

Despite reductions in malaria incidence and mortality across Sub-Saharan (SSA) countries, malaria control and elimination efforts are currently facing multiple global challenges such as climate and land use change, invasive vectors, and disruptions in healthcare delivery. Although relationships between malaria risks and socioeconomic factors have been widely demonstrated, the strengths and variability of these associations have not been quantified across SSA. In this study, we used data from population-based malaria indicator surveys in SSA countries to assess spatial trends in relative and absolute socioeconomic inequalities, analyzed as social (mothers’ highest educational level—MHEL) and economic (wealth index—WI) inequalities in malaria prevalence. To capture spatial variations in socioeconomic (represented by both WI and MHEL) inequalities in malaria, we calculated both the Slope Index of Inequality (SII) and Relative Index of Inequality (RII) in each administrative region. We also conducted cluster analyses based on Local Indicator of Spatial Association (LISA) to consider the spatial auto-correlation in SII and RII across regions and countries. A total of 47,404 participants in 1874 Primary Sampling Units (PSU) were analyzed across the 13 SSA countries. Our multi-country assessment provides estimations of strong socioeconomic inequalities between and within SSA countries. Such within- and between- countries inequalities varied greatly according to the socioeconomic metric and the scale used. Countries located in Eastern Africa showed a higher median Slope Index of Inequality (SII) and Relative Index of Inequality (RII) in malaria prevalence relative to WI in comparison to countries in other locations across SSA. Pockets of high SII in malaria prevalence in relation to WI and MHEL were observed in the East part of Africa. This study was able to map this wide range of malaria inequality metrics at a very local scale and highlighted the spatial clustering patterns of pockets of high and low malaria inequality values.

Determinants of household catastrophic costs for drug sensitive tuberculosis patients in Kenya

Background

Despite free diagnosis and treatment for tuberculosis (TB), the costs during treatment impose a significant financial burden on patients and their households. The study sought to identify the determinants for catastrophic costs among patients with drug-sensitive TB (DSTB) and their households in Kenya.

Methods

The data was collected during the 2017 Kenya national patient cost survey from a nationally representative sample (n = 1071). Treatment related costs and productivity losses were estimated. Total costs exceeding 20% of household income were defined as catastrophic and used as the outcome. Multivariable Poisson regression analysis was performed to measure the association between selected individual, household and disease characteristics and occurrence of catastrophic costs. A deterministic sensitivity analysis was carried using different thresholds and the significant predictors were explored.

Results

The proportion of catastrophic costs among DSTB patients was 27% (n = 294). Patients with catastrophic costs had higher median productivity losses, 39 h [interquartile range (IQR): 20–104], and total median costs of USD 567 (IQR: 299–1144). The incidence of catastrophic costs had a dose response with household expenditure. The poorest quintile was 6.2 times [95% confidence intervals (CI): 4.0–9.7] more likely to incur catastrophic costs compared to the richest. The prevalence of catastrophic costs decreased with increasing household expenditure quintiles (proportion of catastrophic costs: 59.7%, 32.9%, 23.6%, 15.9%, and 9.5%) from the lowest quintile (Q1) to the highest quintile (Q5). Other determinants included hospitalization: prevalence ratio (PR) = 2.8 (95% CI: 1.8–4.5) and delayed treatment: PR = 1.5 (95% CI: 1.3–1.7). Protective factors included receiving care at a public health facility: PR = 0.8 (95% CI: 0.6–1.0), and a higher body mass index (BMI): PR = 0.97 (95% CI: 0.96–0.98). Pre TB expenditure, hospitalization and BMI were significant predictors in all sensitivity analysis scenarios.

Conclusions

There are significant inequities in the occurrence of catastrophic costs. Social protection interventions in addition to existing medical and public health interventions are important to implement for patients most at risk of incurring catastrophic costs.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-021-00879-4.

Characteristics and outcomes of patients with an unscheduled return visit within 72 hours to the Paediatric Emergency Centre at a Private Tertiary Referral Hospital in Kenya

Introduction

Patients’ unscheduled return visits (URVs) to the paediatric emergency Centre (PEC) contribute to overcrowding and affect health service delivery and overall quality of care. This study assessed the characteristics and outcomes of paediatric patients with URVs (within 72 hours) to the PEC at a private tertiary hospital in Kenya.

Methods

We conducted a retrospective chart review of all URVs within 72 hours among paediatric patients aged ≤15 years between 1 July and 31 December 2018 at the tertiary hospital in Nairobi, Kenya.

Results

During the study period, 1.6% (n=172) of patients who visited the PEC returned within 72 hours, with 4.7% revisiting the PEC more than once. Patients’ median age was 36 months (interquartile range: 42 months); over half were male (51.7%), 55.8% were ambulatory and 84.3% were insured. In addition, 21% (n=36) had chronic diseases and 7% (n=12) had drug allergies. Respiratory (59.5%) and gastrointestinal (21.5%) tract infections were the most common diagnoses. Compared with the first visit, more patients with URVs were classified as urgent (1.7% vs. 5.2%) and were non-ambulatory (44.2% vs. 49.5%, p=<0.001); 18% of these patients were admitted. Of these 58% were male, 83.9% were aged 0–5 years, 12.9% were classified as urgent, 64.5% had respiratory tract infections and 16.1% had gastrointestinal tract infections. Being admitted was associated with patient acuity (p=0.004), laboratory tests (p=<0.001) and ambulatory status (p=0.041).

Conclusion

The URV rate is low in our setting. Patients who returned to the PEC within 72 hours tended to be male, under 5 years old and insured. Many were non-urgent cases with diagnoses of respiratory and gastrointestinal tract infections. The findings suggest that some URVs were necessary and may have contributed to better care and improved outcomes while others highlight a need for effective patient education and comprehensive initial assessment.

Exploring patient-provider interactions and the health system's responsiveness to street-connected children and youth in Kenya: a qualitative study

Background

In Kenya, street-connected children and youth (SCY) have poor health outcomes and die prematurely due to preventable causes. This suggests they are not accessing or receiving adequately responsive healthcare to prevent morbidity and mortality. We sought to gain insight into the health systems responsiveness to SCY in Kenya through an in-depth exploration of SCY’s and healthcare provider’s reflections on their interactions with each other.

Methods

This qualitative study was conducted across 5 counties in western Kenya between May 2017 and September 2018 using multiple methods to explore and describe the public perceptions of, and proposed and existing responses to, the phenomenon of SCY in Kenya. The present analysis focuses on a subset of data from focus group discussions and in-depth interviews concerning the delivery of healthcare to SCY, interactions between SCY and providers, and SCY’s experiences in the health system. We conducted a thematic analysis situated in a conceptual framework for health systems responsiveness.

Results

Through three themes, context, negative patient-provider interactions, and positive patient-provider interactions, we identified factors that shape health systems responsiveness to SCY in Kenya. Economic factors influenced and limited SCY’s interactions with the health system and shaped their experiences of dignity, quality of basic amenities, choice of provider, and prompt attention. The stigmatization and discrimination of SCY, a sociological process shaped by the social-cultural context in Kenya, resulted in experiences of indignity and a lack of prompt attention when interacting with the health system. Patient-provider interactions were highly influenced by healthcare providers’ adverse personal emotions and attitudes towards SCY, resulting in negative interactions and a lack of health systems responsiveness.

Conclusions

This study suggests that the health system in Kenya is inadequately responsive to SCY. Increasing public health expenditures and expanding universal health coverage may begin to address economic factors, such as the inability to pay for care, which influence SCY’s experiences of choice of provider, prompt attention, and dignity. The deeply embedded adverse emotional responses expressed by providers about SCY, associated with the socially constructed stigmatization of this population, need to be addressed to improve patient-provider interactions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06376-6.

District division administrative disaggregation data framework for monitoring leaving no one behind in the National Health Insurance Fund of Sudan: achieving sustainable development goals in 2030

BACKGROUND

The aim of this study is to monitor the concept of 'leaving no one behind' in the Sustainable Development Goals (SDGs) to track the implications of the mobilization of health care resources by the National Health Insurance Fund (NHIF) of Sudan.

METHODS

A cross-sectional study was used to monitor 'leaving no one behind' in NHIF by analyzing the secondary data of the information system for the year 2016. The study categorized the catchment areas of health care centers (HCCS) according to district administrative divisions, which are neighborhood, subdistrict, district, and zero. The District Division Administrative Disaggregation Data (DDADD) framework was developed and investigated with the use of descriptive statistics, maps of Sudan, the Mann-Whitney test, the Kruskal-Wallis test and health equity catchment indicators. SPSS ver. 18 and EndNote X8 were also used.

RESULTS

The findings show that the NHIF has mobilized HCCs according to coverage of the insured population. This mobilization protected the insured poor in high-coverage insured population districts and left those living in very low-coverage districts behind. The Mann-Whitney test presented a significant median difference in the utilization rate between catchment areas (P value < 0.001). The results showed that the utilization rate of the insured poor who accessed health care centers by neighborhood was higher than that of the insured poor who accessed by more than neighborhood in each state. The Kruskal-Wallis test of the cost of health care services per capita in each catchment area showed a difference (P value < 0.001) in the median between neighborhoods. The cost of health care services in low-coverage insured population districts was higher than that in high-coverage insured population districts.

CONCLUSION

The DDADD framework identified the inequitable distribution of health care services in low-density population districts leaves insured poor behind. Policymakers should restructure the equation of health insurance schemes based on equity and probability of illness, to distribute health care services according to needs and equity, and to remobilize resources towards districts left behind.

Decomposition of changes in socioeconomic inequalities in catastrophic health expenditure in Kenya

BACKGROUND

Catastrophic health expenditure (CHE) is frequently used as an indicator of financial protection. CHE exists when health expenditure exceeds a certain threshold of household consumption. Although CHE is reported to have declined in Kenya, it is still unacceptably high and disproportionately affects the poor. This study examines the socioeconomic factors that contribute to inequalities in CHE as well as the change in these inequalities over time in Kenya.

METHODS

We used data from the Kenya household health expenditure and utilisation (KHHEUS) surveys in 2007 and 2013. The concertation index was used to measure the socioeconomic inequalities in CHE. Using the Wagstaff (2003) approach, we decomposed the concentration index of CHE to assess the relative contribution of its determinants. We applied Oaxaca-type decomposition to assess the change in CHE inequalities over time and the factors that explain it.

RESULTS

The findings show that while there was a decline in the incidence of CHE, inequalities in CHE increased from -0.271 to -0.376 and was disproportionately concentrated amongst the less well-off. Higher wealth quintiles and employed household heads positively contributed to the inequalities in CHE, suggesting that they disadvantaged the poor. The rise in CHE inequalities overtime was explained mainly by the changes in the elasticities of the household wealth status.

CONCLUSION

Inequalities in CHE are persistent in Kenya and are largely driven by the socioeconomic status of the households. This implies that the existing financial risk protection mechanisms have not been sufficient in cushioning the most vulnerable from the financial burden of healthcare payments. Understanding the factors that sustain inequalities in CHE is, therefore, paramount in shaping pro-poor interventions that not only protect the poor from financial hardship but also reduce overall socioeconomic inequalities. This underscores the fundamental need for a multi-sectoral approach to broadly address existing socioeconomic inequalities.

Devolution of healthcare system in Kenya: progress and challenges

OBJECTIVES

The aim of the present study was to systematically review the progress and challenges on the devolved healthcare system in Kenya.

STUDY DESIGN

A systematic review design was adopted for the present study.

METHODS

Literature search was on biomedical databases of the most recent available electronic data published in English, that is, between January 2012 and April 2020. The populations for eligible studies were stakeholders within the county governments, healthcare workers and community dwellers. The databases included PubMed, EMBASE and Google Scholar. The following were the key words used in the search: 'Devolution of Health' 'Health care system in Kenya' AND 'County Health Facilities' 'challenges' AND 'progress' AND 'Kenya'. Other literature sources were after screening of all the references of all the added articles. Before the development of search terms, we looked for appropriate Medical Subject Headings terms and applied with maximal truncations. The data were qualitatively analysed, and findings were presented by three thematic domains.

RESULTS

The search generated 1109 articles, of which 23 articles met the inclusion criteria. Data were presented and organized under three thematic domains: (1) localised decision-making process, (2) improvement in structural development and (3) inadequate resources/funds/staff.

CONCLUSION

This is a systematic review which, to the best of our knowledge, is the first study of its kind to present the available evidence on the progress and challenges on the devolved healthcare system in Kenya. The major findings of this review were as follows: there was improvement in the health structural development that was brought by devolution in the country. However, devolution is not free of challenges. The major challenges noted in the postdevolution era within the health sector include inadequate resources/funds from the national government and understaffed health facilities. The study recommends allocation of resources to counties commensurate with the devolved functions. The study calls out for further research on equity and equality of the devolved healthcare system in Kenya.

The impact of COVID-19 control measures on social contacts and transmission in Kenyan informal settlements

BACKGROUND

Many low- and middle-income countries have implemented control measures against coronavirus disease 2019 (COVID-19). However, it is not clear to what extent these measures explain the low numbers of recorded COVID-19 cases and deaths in Africa. One of the main aims of control measures is to reduce respiratory pathogen transmission through direct contact with others. In this study, we collect contact data from residents of informal settlements around Nairobi, Kenya, to assess if control measures have changed contact patterns, and estimate the impact of changes on the basic reproduction number (R0).

METHODS

We conducted a social contact survey with 213 residents of five informal settlements around Nairobi in early May 2020, 4 weeks after the Kenyan government introduced enhanced physical distancing measures and a curfew between 7 pm and 5 am. Respondents were asked to report all direct physical and non-physical contacts made the previous day, alongside a questionnaire asking about the social and economic impact of COVID-19 and control measures. We examined contact patterns by demographic factors, including socioeconomic status. We described the impact of COVID-19 and control measures on income and food security. We compared contact patterns during control measures to patterns from non-pandemic periods to estimate the change in R0.

RESULTS

We estimate that control measures reduced physical contacts by 62% and non-physical contacts by either 63% or 67%, depending on the pre-COVID-19 comparison matrix used. Masks were worn by at least one person in 92% of contacts. Respondents in the poorest socioeconomic quintile reported 1.5 times more contacts than those in the richest. Eighty-six percent of respondents reported a total or partial loss of income due to COVID-19, and 74% reported eating less or skipping meals due to having too little money for food.

CONCLUSION

COVID-19 control measures have had a large impact on direct contacts and therefore transmission, but have also caused considerable economic and food insecurity. Reductions in R0 are consistent with the comparatively low epidemic growth in Kenya and other sub-Saharan African countries that implemented similar, early control measures. However, negative and inequitable impacts on economic and food security may mean control measures are not sustainable in the longer term.

Measuring and decomposing socioeconomic-related inequality in the use of oral health services among Chinese adults

OBJECTIVES

This study aimed to measure socioeconomic-related inequality and horizontal inequity in the use of oral health services and decompose this inequality among adults of different age groups in China.

METHODS

In total, 10 973 adults (3669 aged 35-44 years, 3767 aged 55-64 years and 3537 aged 65-74 years) who participated in the 4th National Oral Health Survey (2015-2016) in China were included. Concentration curves and the Erreygers-corrected concentration index (EI) were employed to measure socioeconomic-related inequality in the use of oral health services. Then, inequity in this utilization was measured by the horizontal inequity index (HI). Furthermore, decomposition analyses were conducted for the three groups to explain the contributions of income level, need factors (ie self-assessed oral health and evaluated oral health status), other factors (ie sex, residential location, educational attainment level and type of basic insurance) and a residual term to overall inequality in oral health service utilization.

RESULTS

The significant positive EI and HI values indicated that pro-rich inequality and inequity in oral health service utilization exist among Chinese adults. Income and type of basic medical insurance contributed the most to socioeconomic-related inequality in the use of oral health services among adults aged 55-64 and 65-74 years. However, the main driving factors of socioeconomic inequality among adults aged 35-44 years in dental care use included income, educational achievement, type of basic medical insurance and residential location. The need variables accounted for a very small proportion of overall socioeconomic-related inequality in oral health service use in all three groups.

CONCLUSIONS

Oral healthcare service utilization was disproportionately concentrated among better-off Chinese adults. The primary determinants of inequality in dental care use in different age groups provide information for policymakers to create more targeted policies to achieve equity in the oral healthcare system in China.

The relationship between a microfinance-based healthcare delivery platform, health insurance coverage, health screenings, and disease management in rural Western Kenya

BACKGROUND

Structural barriers often prevent rural Kenyans from receiving healthcare and diagnostic testing. The Bridging Income Generation through grouP Integrated Care (BIGPIC) Family intervention facilitates microfinance groups, provides health screenings and treatment, and delivers education about health insurance coverage to address some of these barriers. This study evaluated the association between participation in BIGPIC microfinance groups and health screening/disease management outcomes.

METHODS

From November 2018 to March 2019, we interviewed a sample of 300 members of two rural communities in Western Kenya, 100 of whom were BIGPIC microfinance members. We queried participants about their experiences with health screening and disease management for HIV, diabetes, hypertension, tuberculosis, and cervical cancer. We used log-binomial regression models to estimate the association between microfinance membership and each health outcome, adjusting for key covariates.

RESULTS

Microfinance members were more likely to be screened for most of the health conditions we queried, including those provided by BIGPIC [e.g. diabetes: aPR (95% CI): 3.46 (2.60, 4.60)] and those not provided [e.g. cervical cancer: aPR (95% CI): 2.43 (1.21, 4.86)]. Microfinance membership was not significantly associated with health insurance uptake and disease management outcomes.

CONCLUSIONS

In rural Kenya, a microfinance program integrated with healthcare delivery may be effective at increasing health screening. Interventions designed to thoughtfully and sustainably address structural barriers to healthcare will be critical to improving the health of those living in low-resource settings.

Design of Appropriate Technology-Assisted Urine Tester Enabling Remote and Long-Term Monitoring of Health Conditions

A novel design idea supported by affordable design processes can address unresolved social problems such as the imbalance of opportunity in healthcare services, owing to high costs and a lack of access. We designed an appropriate technology-assisted urine tester to provide healthcare services for the elderly and underprivileged in order to monitor their health conditions daily and remotely help them determine whether to visit hospitals/clinics for in-depth diagnoses. To minimize production costs, we used a charge-coupled device camera for colorimetric-type urine analysis in conjunction with commercially available urine test strips; all other electronic components were mass-produced. We calibrated this urine tester and compared it with a commercially available high-end tester; the results showed high accuracy for most urine compounds. We verified its major device functions by recruiting four participants who tested their urine over four weeks and provided self-surveys of their health conditions. The proposed tester demonstrates a low price-to-performance ratio with high reliability, while its production and maintenance costs are as low as 20 USD per set. We focused on a human-centered technological approach from a simple and innovative design point of view in order to serve people and healthcare providers in an affordable way. We believe that the tester can be widely distributed, exemplifying appropriate technological application for those who require, but cannot enjoy, proper medical services, thereby improving social healthcare sustainability.