Addressing social determinants of health by integrating assessment of caregiver-child attachment into community based primary health care in urban Kenya.

A principle strategic insight of the Final Report for WHO's Commission on Social Determinants of Health (SDOH) is that the nurturant qualities of the environments where children grow up, live, and learn matter the most for their development. A key determinant of early childhood development is the establishment of a secure attachment between a caregiver and child. We report initial field-tests of the integration of caregiver-child attachment assessment by community health workers (CHWs) as a routine component of Primary Health Care (PHC), focusing on households with children under 5 years of age in three slum communities near Nairobi, Kenya. Of the 2,560 children assessed from July-December 2010, 2,391 (90.2%) were assessed as having a secure attachment with a parent or other caregiver, while 259 (9.8%) were assessed as being at risk for having an insecure attachment. Parent workshops were provided as a primary intervention, with re-enforcement of teachings by CHWs on subsequent home visits. Reassessment of attachment by CHWs showed positive changes. Assessment of caregiver-child attachment in the setting of routine home visits by CHWs in a community-based PHC context is feasible and may yield valuable insights into household-level risks, a critical step for understanding and addressing the SDOH.

Global health: evolving meanings.

Approaches to health, health care, and the terminology to describe global health have evolved over the past 70 years since the introduction of the Constitution of the World Health Organization and definition of health in broader terms. The early focus on individual care gradually shifted to community, population, and global approaches, with associated changes in the site of medical care, the personnel who provide it, and the education and training of those personnel. Concomitantly, goals changed from purely curative care to disease prevention and health promotion. Health was better understood to exist within the larger political, social, cultural, and ethical settings.

Global health and the role of universities in the twenty-first century.

A vast gap exists between knowledge, generation of knowledge, and the application of knowledge to the needs and benefit of the global population. In middle-income and lower-income countries, universities are becoming more engaged with the communities in which they are located to try to solve the difficult problems of poverty and poor health. Global collaborations and reform of medical education in the twenty-first century will help move universities out of cloistered academic settings and into the community to bring the changes needed to equitably meet the health needs of all.

Kenya's cash transfer program: protecting the health and human rights of orphans and vulnerable children.

In Kenya, as in other countries of sub-Saharan Africa heavily burdened by HIV/ AIDS, orphans and vulnerable children (OV/C) face poverty and despair. There is an urgent need to provide a comprehensive response that supports families and communities in their efforts to care for children and safeguard their rights. The government of Kenya has established a cash transfer program that delivers financial and social support directly to the poorest households containing OV/C, with special concern for those children with or affected by HIV/AIDS. The Kenyan effort builds on lessons drawn from research and program development on cash transfers in Latin America, Asia, and Africa, and the Kenyan program offers an opportunity to examine the challenges faced by Kenya, and its responses in the context of international experiences. This paper-based on observation of and interviews with key actors involved in the origins, development, evaluation, and continued strengthening of Kenyas cash transfer program and on the analysis of technical program documents obtained from those key actors--describes the Kenyan cash transfer program in light of human rights issues as they relate to childrens health. It offers one example of how caring for society's most vulnerable members is a collective responsibility to be shared by a country's government, local citizens, and the international community.

Health equity issues at the local level: socio-geography, access, and health outcomes in the service area of the Hôpital Albert Schweitzer-Haiti.

BACKGROUND: Although health equity issues at regional, national and international levels are receiving increasing attention, health equity issues at the local level have been virtually overlooked. Here, we describe here a comprehensive equity assessment carried out by the Hôpital Albert Schweitzer-Haiti (HAS) in 2003. HAS has been operating health and development programs in the Artibonite Valley of Haiti for 50 years. METHODS: We reviewed all available information arising from a comprehensive evaluation of the programs of HAS carried out in 1999 and 2000. As part of this evaluation, two demographic and health surveys were carried out. We carried out exit interviews with clients receiving primary health care, observations within health facilities, interviews with households related to quality of care, and focus group discussions with community-based health workers. A special study was carried out in 2003 to assess factors determining the use of prenatal care services. Finally, selected findings were obtained from the HAS information system. RESULTS: We found markedly reduced access to health services in the peripheral mountainous areas compared to the central plains. The quality of services was more deficient and the coverage of key services was lower in the mountains. Finally, health status, as measured by under-five mortality rates and levels of childhood malnutrition, was also worse in the mountains. CONCLUSION: These findings indicate that local health programs need to give attention to monitoring the health status as well as the quality and coverage of basic services among marginalized groups within the program service area. Health inequities will not be overcome until such monitoring occurs and leaders of health programs ensure that inequities identified are addressed in the local programming of activities. It is quite likely that, within relatively small geographic areas in resource-poor settings around the world, similar, if not even greater, levels of health inequities exist. These inequities need to be measured and addressed in order for health programs to achieve equity and maximum improvement in health status within the population.

An evidence-based approach to benchmarking the fairness of health-sector reform in developing countries.

The Benchmarks of Fairness instrument is an evidence-based policy tool developed in generic form in 2000 for evaluating the effects of health-system reforms on equity, efficiency and accountability. By integrating measures of these effects on the central goal of fairness, the approach fills a gap that has hampered reform efforts for more than two decades. Over the past three years, projects in developing countries on three continents have adapted the generic version of these benchmarks for use at both national and subnational levels. Interdisciplinary teams of managers, providers, academics and advocates agree on the relevant criteria for assessing components of fairness and, depending on which aspects of reform they wish to evaluate, select appropriate indicators that rely on accessible information; they also agree on scoring rules for evaluating the diverse changes in the indicators. In contrast to a comprehensive index that aggregates all measured changes into a single evaluation or rank, the pattern of changes revealed by the benchmarks is used to inform policy deliberation aboutwhich aspects of the reforms have been successfully implemented, and it also allows for improvements to be made in the reforms. This approach permits useful evidence about reform to be gathered in settings where existing information is underused and where there is a weak information infrastructure. Brief descriptions of early results from Cameroon, Ecuador, Guatemala, Thailand and Zambia demonstrate that the method can produce results that are useful for policy and reveal the variety of purposes to which the approach can be put. Collaboration across sites can yield a catalogue of indicators that will facilitate further work.