Measuring health science research and development in Africa: mapping the available data.

BACKGROUND: In recent years there have been calls to strengthen health sciences research capacity in African countries. This capacity can contribute to improvements in health, social welfare and poverty reduction through domestic application of research findings; it is increasingly seen as critical to pandemic preparedness and response. Developing research infrastructure and performance may reduce national economies' reliance on primary commodity and agricultural production, as countries strive to develop knowledge-based economies to help drive macroeconomic growth. Yet efforts to date to understand health sciences research capacity are limited to output metrics of journal citations and publications, failing to reflect the complexity of the health sciences research landscape in many settings. METHODS: We map and assess current capacity for health sciences research across all 54 countries of Africa by collecting a range of available data. This included structural indicators (research institutions and research funding), process indicators (clinical trial infrastructures, intellectual property rights and regulatory capacities) and output indicators (publications and citations). RESULTS: While there are some countries which perform well across the range of indicators used, for most countries the results are varied-suggesting high relative performance in some indicators, but lower in others. Missing data for key measures of capacity or performance is also a key concern. Taken as a whole, existing data suggest a nuanced view of the current health sciences research landscape on the African continent. CONCLUSION: Mapping existing data may enable governments and international organizations to identify where gaps in health sciences research capacity lie, particularly in comparison to other countries in the region. It also highlights gaps where more data are needed. These data can help to inform investment priorities and future system needs.

Governance of health research in four eastern and southern African countries.

BACKGROUND: Health research governance is an essential function of national health research systems. Yet many African countries have not developed strong health research governance structures and processes. This paper presents a comparative analysis of national health research governance in Botswana, Kenya, Uganda and Zambia, where health sciences research production is well established relative to some others in the region and continues to grow. The paper aims to examine progress made and challenges faced in strengthening health research governance in these countries. METHODS: We collected data through document review and key informant interviews with a total of 80 participants including decision-makers, researchers and funders across stakeholder institutions in the four countries. Data on health research governance were thematically coded for policies, legislation, regulation and institutions and analysed comparatively across the four national health research systems. RESULTS: All countries were found to be moving from using a research governance framework set by national science, technology and innovation policies to one that is more anchored in health research structures and policies within the health sectors. Kenya and Zambia have adopted health research legislation and policies, while Botswana and Uganda are in the process of developing the same. National-level health research coordination and regulation is hampered by inadequate financial and human resource capacities, which present challenges for building strong health research governance institutions. CONCLUSION: Building health research governance as a key pillar of national health research systems involves developing stronger governance institutions, strengthening health research legislation, increasing financing for governance processes and improving human resource capacity in health research governance and management.

Beyond the metrics of health research performance in African countries.

While it is important to be able to evaluate and measure a country's performance in health research (HR), HR systems are complex and multifaceted in nature. As such, attempts at measurement can suffer several limitations which risk leading to inadequate indices or representations. In this study, we critically review common indicators of HR capacity and performance and explore their strengths and limitations. The paper is informed by review of data sources and documents, combined with interviews and peer-to-peer learning activities conducted with officials working in health and education ministries in a set of nine African countries. We find that many metrics that can assess HR performance have gaps in the conceptualisation or fail to address local contextual realities, which makes it a challenge to interpret them in relation to other theoretical constructs. Our study identified several concepts that are excluded from current definitions of indicators and systems of metrics for HR performance. These omissions may be particularly important for interpreting HR performance within the context and processes of HR in African countries, and thus challenging the relevance, utility, appropriateness and acceptability of universal measures of HR in the region. We discuss the challenges that scholars may find in conceptualising such a complex phenomenon-including the different and competing viewpoints of stakeholders, in setting objectives of HR measurement work, and in navigating the realities of empirical measurement where missing or partial data may necessitate that proxies or alternative indicators may be chosen. These findings are important to ensure that the global health community does not rely on over-simplistic evaluations of HR when analysing and planning for improvements in low-income and middle-income countries.

Nutrition-related non-communicable disease and sugar-sweetened beverage policies: a landscape analysis in Kenya.

Background: The burden of undernutrition is significant in Kenya. Obesity and related non-communicable diseases are also on the increase. Government action to prevent non-communicable diseases is critical. Taxation of sugar-sweetened beverages has been identified as an effective mechanism to address nutrition-related non-communicable diseases, although Kenya is not yet committed to this.Objective: To assess the policy and stakeholder landscape relevant to nutrition related non -communicable diseases and sugar-sweetened beverage taxation in Kenya.Methods: A desk review of evidence and policies related to nutrition related non-communicable diseases and sugar-sweetened beverages was conducted. Data extraction matrices were used for analysis. Key informant interviews were conducted with 10 policy actors. Interviews were thematically analysed to identify enablers of, and barriers to, policy change towards nutrition-sweetened beverage taxation.Results: Although nutrition related non-communicable diseases are recognised as a growing problem in Kenya most food-related policies focus on undernutrition and food security, while underplaying the role of nutrition related non-communicable diseases. Policy development on communicable diseases is multi-sectoral, but implementation is biased towards curative rather than preventive services. An excise tax is charged on soft drinks, but is not specific to sugar-sweetened beverages. Government has competing roles: advocating for industrial growth, such as sugar and food processing industries to foster economic development, yet wanting to control nutrition related non-communicable diseases. There is no national consensus about the dangers posed by sugar-sweetened beverages.Conclusion: Nutrition related non-communicable diseases policies should reflect a continuum of issues, from undernutrition to food security, nutrition transition, and the escalation of nutrition related non-communicable diseases. A local advocacy case for sugar-sweetened beverage taxation has not been made. Public and policy maker education is critical to challenge the prevailing attitudes towards sugar-sweetened beverages and the western diet.

Fighting non-communicable diseases in East Africa: assessing progress and identifying the next steps.

Sub-Saharan Africa has seen a rapid increase in non-communicable disease (NCD) burden over the last decades. The East African Community (EAC) comprises Burundi, Rwanda, Kenya, Tanzania, South Sudan and Uganda, with a population of 177 million. In those countries, 40% of deaths in 2015 were attributable to NCDs. We review the status of the NCD response in the countries of the EAC based on the available monitoring tools, the WHO NCD progress monitors in 2017 and 2020 and the East African NCD Alliance benchmark survey in 2017. In the EAC, modest progress in governance, prevention of risk factors, monitoring, surveillance and evaluation of health systems can be observed. Many policies exist on paper, implementation and healthcare are weak and there are large regional and subnational differences. Enhanced efforts by regional and national policy-makers, non-governmental organisations and other stakeholders are needed to ensure future NCD policies and implementation improvements.

First Africa non-communicable disease research conference 2017: sharing evidence and identifying research priorities.

Non-communicable diseases (NCDs) prevalence is rising fastest in lower income settings, and with more devastating outcomes compared to High Income Countries (HICs). While evidence is consistent on the growing health and economic consequences of NCDs in sub-Saharan Africa (SSA), specific efforts aimed at addressing NCD prevention and control remain less than optimum and country level progress of implementing evidence backed cost-effective NCD prevention approaches such as tobacco taxation and restrictions on marketing of unhealthy food and drinks is slow. Similarly, increasing interest to employ multi-sectoral approaches (MSA) in NCD prevention and policy is impeded by scarce knowledge on the mechanisms of MSA application in NCD prevention, their coordination, and potential successes in SSA. In recognition of the above gaps in NCD programming and interventions in Africa, the East Africa NCD alliance (EANCDA) in partnership with the African Population and Health Research Center (APHRC) organized a three-day NCDs conference in Nairobi. The conference entitled "First Africa Non-Communicable Disease Research Conference 2017: Sharing Evidence and Identifying Research Priorities" drew more than one hundred fifty participants and researchers from several institutions in Kenya, South Africa, Nigeria, Cameroon, Uganda, Tanzania, Rwanda, Burundi, Malawi, Belgium, USA and Canada. The sections that follow provide detailed overview of the conference, its objectives, a summary of the proceedings and recommendations on the African NCD research agenda to address NCD prevention efforts in Africa.

Multi-sectoral action in non-communicable disease prevention policy development in five African countries.

BACKGROUND: The rise of non-communicable diseases (NCDs) in Africa requires a multi-sectoral action (MSA) in their prevention and control. This study aimed to generate evidence on the extent of MSA application in NCD prevention policy development in five sub-Saharan African countries (Kenya, South Africa, Cameroon, Nigeria and Malawi) focusing on policies around the major NCD risk factors. METHODS: The broader study applied a multiple case study design to capture rich descriptions of policy contents, processes and actors as well as contextual factors related to the policies around the major NCD risk factors at single- and multi-country levels. Data were collected through document reviews and key informant interviews with decision-makers and implementers in various sectors. Further consultations were conducted with NCD experts on MSA application in NCD prevention policies in the region. For this paper, we report on how MSA was applied in the policy process. RESULTS: The findings revealed some degree of application of MSA in NCD prevention policy development in these countries. However, the level of sector engagement varies across different NCD policies, from passive participation to active engagement, and by country. There was higher engagement of sectors in developing tobacco policies across the countries, followed by alcohol policies. Multi-sectoral action for tobacco and to some extent, alcohol, was enabled through established structures at national levels including inter-ministerial and parliamentary committees. More often coordination was enabled through expert or technical working groups driven by the health sectors. The main barriers to multi-sectoral action included lack of awareness by various sectors about their potential contribution, weak political will, coordination complexity and inadequate resources. CONCLUSION: MSA is possible in NCD prevention policy development in African countries. However, the findings illustrate various challenges in bringing sectors together to develop policies to address the increasing NCD burden in the region. Stronger coordination mechanisms with clear guidelines for sector engagement are required for effective MSA in NCD prevention. Such a mechanisms should include approaches for capacity building and resource generation to enable multi-sectoral action in NCD policy formulation, implementation and monitoring of outcomes.

Non-communicable disease prevention policy process in five African countries.

BACKGROUND: The increasing burden of non-communicable diseases (NCDs) in sub-Saharan Africa is causing further burden to the health care systems that are least equipped to deal with the challenge. Countries are developing policies to address major NCD risk factors including tobacco use, unhealthy diets, harmful alcohol consumption and physical inactivity. This paper describes NCD prevention policy development process in five African countries (Kenya, South Africa, Cameroon, Nigeria, Malawi), including the extent to which WHO "best buy" interventions for NCD prevention have been implemented. METHODS: The study applied a multiple case study design, with each country as a separate case study. Data were collected through document reviews and key informant interviews with national-level decision-makers in various sectors. Data were coded and analyzed thematically, guided by Walt and Gilson policy analysis framework that examines the context, content, processes and actors in policy development. RESULTS: Country-level policy process has been relatively slow and uneven. Policy process for tobacco has moved faster, especially in South Africa but was delayed in others. Alcohol policy process has been slow in Nigeria and Malawi. Existing tobacco and alcohol policies address the WHO "best buy" interventions to some extent. Food-security and nutrition policies exist in almost all the countries, but the "best buy" interventions for unhealthy diet have not received adequate attention in all countries except South Africa. Physical activity policies are not well developed in any study countries. All have recently developed NCD strategic plans consistent with WHO global NCD Action Plan but these policies have not been adequately implemented due to inadequate political commitment, inadequate resources and technical capacity as well as industry influence. CONCLUSION: NCD prevention policy process in many African countries has been influenced both by global and local factors. Countries have the will to develop NCD prevention policies but they face implementation gaps and need enhanced country-level commitment to support policy NCD prevention policy development for all risk factors and establish mechanisms to attain better policy outcomes while considering other local contextual factors that may influence policy implementation such as political support, resource allocation and availability of local data for monitoring impacts.

Two decades of tobacco use prevention and control policies in Cameroon: results from the analysis of non-communicable disease prevention policies in Africa.

BACKGROUND: Tobacco use is the leading cause of preventable death in the world today. In 2010, the World Health Organization (WHO) proposed efficient and inexpensive "best buy" interventions for prevention of tobacco use including: tax increases, smoke-free indoor workplaces and public places, bans on tobacco advertising, promotion and sponsorship, and health information and warnings. This paper analyzes the extent to which tobacco use prevention policies in Cameroon align with the WHO tobacco "best buy" interventions. It further explores the context, content, formulation and implementation level of these policies. METHODS: This was a case study combining a structured review of 19 government policy documents related to tobacco use and prevention, in-depth interviews with 38 key stakeholders and field observations. The Walt and Gilson's policy analysis triangle was used to describe and interpret the context, content, processes and actors during the formulation and implementation of tobacco prevention and control policies. Direct observations ascertained the level of implementation of some selected policies. RESULTS: Twelve out of 19 policies for tobacco use and prevention address the WHO "best buy" interventions. Cameroon policy formulation was driven locally by the social context of non-communicable diseases, and globally by the adoption of the WHO Framework Convention on Tobacco Control. These policies incorporated at a certain level all four domains of tobacco use "best buy" interventions. Formulating policy on smoke-free areas was single-sector oriented, while determining tobacco taxes and health warnings was more complex utilizing multisectoral approaches. The main actors involved were ministerial departments of Health, Education, Finances, Communication and Social Affairs. The level of implementation varied widely from one policy to another and from one region to another. Political will, personal motivation and the existence of formal exchange platforms facilitated policy formulation and implementation, while poor resource allocation and lack of synergy constituted barriers. CONCLUSIONS: Despite actions made by the Government, there is no real political will to control tobacco use in Cameroon. Significant shortcomings still exist in developing and/or implementing comprehensive tobacco use and prevention policies. These findings highlight major gaps as well as opportunities that can be harnessed to improve tobacco control in Cameroon.

Correction to: Non-communicable disease prevention policy process in five African countries.

After publication of the article [1], it was noticed that the title has erroneously included 'authors' in the end.

Opportunities and challenges for evidence-informed HIV-noncommunicable disease integrated care policies and programs: lessons from Malawi, South Africa, Swaziland and Kenya.

INTRODUCTION: Countries in sub-Saharan Africa (SSA) are recognizing the growing dual burden of HIV and noncommunicable diseases (NCDs). This article explores the availability, implementation processes, opportunities and challenges for policies and programs for HIV/NCD integration in four SSA countries: Malawi, Kenya, South Africa and Swaziland. METHODS: We conducted a cross-sectional analysis of current policies and programs relating to HIV/NCD care integration from January to April 2017 using document review and expert opinions. The review focussed on availability and content of relevant policy documents and processes towards implementating national HIV/NCD integration policies. RESULTS: All four case study countries had at least one policy document including aspects of HIV/NCD care integration. Apart from South Africa that had a phased nation-wide implementation of a comprehensive integrated chronic disease model, the three other countries - Malawi, Kenya and Swaziland, had either pilot implementations or nation-wide single-disease integration of NCDs and HIV. Opportunities for HIV/NCD integration policies included: presence of overarching health policy documents that recognize the need for integration, and coordinated action by policymakers, researchers and implementers. Evidence gaps for cost-effectiveness, effects of integration on key HIV and NCD outcomes and funding mechanisms for sustained implementation of integrated HIV/NCD care strategies, were among challenges identified. CONCLUSION: Policymakers in Malawi, Kenya, South Africa and Swaziland have considered integration of NCD and HIV care but a lack of robust evidence hampers large-scale implementation of HIV/NCD integration. It is crucial for SSA Ministries of Health and throughout low-and-middle-income countries to utilize existing opportunities and advocate for evidence-informed HIV/NCD integration strategies.

Policy environment for prevention, control and management of cardiovascular diseases in primary health care in Kenya.

BACKGROUND: In Kenya, cardiovascular diseases (CVDs) accounted for more than 10% of total deaths and 4% of total Disability-Adjusted Life Years (DALYs) in 2015 with a steady increase over the past decade. The main objective of this paper was to review the existing policies and their content in relation to prevention, control and management of CVDs at primary health care (PHC) level in Kenya. METHODS: A targeted document search in Google engine using keywords "Kenya national policy on cardiovascular diseases" and "Kenya national policy on non-communicable diseases (NCDs)" was conducted in addition to key informant interviews with Kenyan policy makers. Relevant regional and international policy documents were also included. The contents of documents identified were reviewed to assess how well they aligned with global health policies on CVD prevention, control and management. Thematic content analysis of the key informant interviews was also conducted to supplement the document reviews. RESULTS: A total of 17 documents were reviewed and three key informants interviewed. Besides the Tobacco Control Act (2007), all policy documents for CVD prevention, control and management were developed after 2013. The national policies were preceded by global initiatives and guidelines and were similar in content with the global policies. The Kenya health policy (2014-2030), The Kenya Health Sector Strategic and Investment Plan (2014-2018) and the Kenya National Strategy for the Prevention and Control of Non-communicable diseases (2015-2020) had strategies on NCDs including CVDs. Other policy documents for behavioral risk factors (The Tobacco Control Act 2007, Alcoholic Drinks Control (Licensing) Regulations (2010)) were available. The National Nutrition Action Plan (2012-2017) was available as a draft. Although Kenya has a tiered health care system comprising primary healthcare, integration of CVD prevention and control at PHC level was not explicitly mentioned in the policy documents. CONCLUSION: This review revealed important gaps in the policy environment for prevention, control and management of CVDs in PHC settings in Kenya. There is need to continuously engage the ministry of health and other sectors to prioritize inclusion of CVD services in PHC.

Barriers to postpartum contraception: differences among women based on parity and future fertility desires.

Timely use of contraception in the postpartum year is critical for pregnancy spacing, which protects a mother's health and improves her ability to care for children. This qualitative study explored contraceptive decision-making among postpartum women in Nairobi, Kenya, with a focus on accounts of how women overcame barriers to postpartum contraceptive use. Focus groups (n = 61) and in-depth interviews (n = 30) explored experiences, barriers and actual use of postpartum contraception. Data were analysed using framework analysis, a method that organises qualitative data into themes and then interprets the data by mapping participant characteristics to these themes. Contraceptive use among women who desired future fertility was hindered by fear of side-effects and concern for partner disapproval. However, women who were satisfied with their family size more easily overcame these barriers. Tailoring postpartum contraceptive counselling to both assuage the concerns of women who desire future fertility and address the long-term contraceptive needs of mothers who desire to stop child-bearing could play a role in reducing the unmet need for contraception. .

Analysis of Non-communicable disease prevention policies in five Sub-Saharan African countries: Study protocol.

BACKGROUND: The burden of non-communicable diseases (NCDs) and their risk factors is increasing in sub-Saharan Africa, and there have been calls for adopting a multi-sectoral approach in developing policies and programs to address this burden. Evidence exists largely from high-income countries on the success (and lack thereof) of multi-sectoral approach in improving population level health outcomes. In sub-Saharan Africa, there is limited research on the application and success of multi-sectoral approach in the formulation and implementation of policies aimed at prevention of non-communicable diseases. Therefore, this protocol describes a study that aims to primarily generate evidence on the extent to which multi-sectoral approach has been applied in developing policies to prevent non-communicable disease in six countries in sub-Saharan Africa -Kenya, Malawi, Nigeria, Cameroon, Togo and South Africa. METHODS/DESIGN: The study applies a multiple case study design. Data will be collated mainly through document reviews and key informant interviews with the relevant decision makers in various sectors. In each country, a detailed case study analysis will be undertaken of any policy/policies developed, adopted and implemented, aimed at implementing the World Health Organization recommended "best buys" for non-communicable disease prevention. These case studies will be conducted by research teams in each country; each team includes a senior research fellow supported by a doctoral student, and research assistants. DISCUSSION: Uptake of the evidence generated from the case studies will be ensured by systematic engagement with policy makers in each country throughout the research process. Ultimately, a forum of experts will be convened to generate actionable recommendations on the use of multi-sectoral approach in non-communicable disease prevention policies in the region.

Altogether now... understanding the role of international organizations in iCCM policy transfer.

INTRODUCTION: Policy transfer theories explain how policy ideas move across time and geography and offer an approach to understanding waves of policy change, a common phenomenon in global health. Four primary mechanisms for the transfer of policies from global to national levels are posited: learning, coercion, socialization and competition. METHODS: We used six concurrent country case studies of policy change for child survival followed by a global study to analyse (1) mechanisms for policy transfer and (2) the roles of international organizations in promoting policy transfer. Our six country cases drew upon early adopters of integrated Community Case Management of Childhood Illness policy (Malawi, Niger), as well as countries that were slower to adopt due either to practical implementation challenges (Mozambique, Mali) and/or policy resistance (Burkina Faso, Kenya). In total, 145 semi-structured interviews and 283 document reviews were conducted across the six country cases, and 25 semi-structured interviews and 72 document reviews for the global study. RESULTS: Three of the four diffusion mechanisms (learning, coercion and socialization) were important in these cases, but not competition. Multiple strategies were employed by multilateral organizations to support policy transfer, such as regional meetings or academic publications, frequently serving multiple diffusion mechanisms simultaneously (e.g. both learning and socialization). In just one country case, funding conditionalities were used to press for policy change. The emphasis of policy transfer mechanisms varied between early and later adopters. Early adopters, for example, were more likely to engage in learning. International multilateral organizations were active policy transfer agents, and national policy-makers perception of them as "trusted partners" made them well suited for this role. However, on occasion their role became more that of advocates than neutral facilitators. CONCLUSIONS: International actors use multiple synergistic channels to promote uptake of global health policies in low- and middle-income countries, and tailor strategies employed to country contexts.

Evidence-informed policymaking in practice: country-level examples of use of evidence for iCCM policy.

Integrated Community Case Management of Childhood Illness (iCCM) is a policy for providing treatment for malaria, diarrhoea and pneumonia for children below 5 years at the community level, which is generating increasing evidence and support at the global level. As countries move to adopt iCCM, it becomes important to understand how this growing evidence base is viewed and used by national stakeholders. This article explores whether, how and why evidence influenced policy formulation for iCCM in Niger, Kenya and Mozambique, and uses Carol Weiss' models of research utilization to further explain the use of evidence in these contexts. A documentary review and in-depth stakeholder interviews were conducted as part of retrospective case studies in each study country. Findings indicate that all three countries used national monitoring data to identify the issue of children dying in the community prior to reaching health facilities, whereas international research evidence was used to identify policy options. Nevertheless, policymakers greatly valued local evidence and pilot projects proved critical in advancing iCCM. World Health Organization and United Nations Children's Fund (UNICEF) functioned as knowledge brokers, bringing research evidence and experiences from other countries to the attention of local policymakers as well as sponsoring site visits and meetings. In terms of country-specific findings, Niger demonstrated both Interactive and Political models of research utilization by using iCCM to capitalize on the existing health infrastructure. Both Mozambique and Kenya exhibit Problem-Solving research utilization with different outcomes. Furthermore, the persistent quest for additional evidence suggests a Tactical use of research in Kenya. Results presented here indicate that while evidence from research studies and other contexts can be critical to policy development, local evidence is often needed to answer key policymaker questions. In the end, evidence may not be enough to overcome resistance if the policy is viewed as incompatible with national goals.

Integrated community case management for childhood illnesses: explaining policy resistance in Kenya.

BACKGROUND: There has been a re-emphasis recently on community health workers to provide child health care services including integrated community case management for childhood illness (iCCM). This research analysed iCCM policy development in Kenya and in particular the types of decision-making criteria used by Kenyan policy-makers in considering whether to advance iCCM policy. METHOD: Data were collected through document reviews (n = 41) and semi-structured interviews (n = 19) with key stakeholders in iCCM policy including government officials, development partners, bilateral donors, and civil society organizations. Initial analysis was guided by the policy triangle with further analysis of factors affecting policy decision-making drawing upon a simple framework developed by Grindle and Thomas (Policy makers, policy choices and policy outcomes: the political economy of reform in developing countries. 1989; Policy Sci 22: :213-48.). FINDINGS: Policy development for iCCM has been slow in Kenya, compared with other Sub-Saharan African countries. At the time of the study, the Government had just completed the Community Health Training Manual which incorporated iCCM as a module, but this was the only formal expression of iCCM in Kenya. We found technical considerations, notably concerns about community health workers dispensing antibiotics to be a key factor slowing iCCM policy development, but this also overlapped with bureaucratic considerations, such as how the development of community health worker cadres may affect clinicians, as well as initial concerns about how an integrated approach might affect vertically oriented programs. International actors through agreements such as the Millennium Development Goals helped to get child survival onto the national policy agenda and such actors were active promoters of iCCM policy change. However international funders had not committed funding to scale-up iCCM policy, and this probably constrained their influence over iCCM policy debate. CONCLUSION: Kenyan actors' concerns about iCCM underline the importance of adapting global policies to local conditions, and also generating local evidence to inform decision-making.

Why do women choose private over public facilities for family planning services? A qualitative study of post-partum women in an informal urban settlement in Kenya.

BACKGROUND: Nearly 40% of women in developing countries seek contraceptives services from the private sector. However, the reasons that contraceptive clients choose private or public providers are not well studied. METHODS: We conducted six focus groups discussions and 51 in-depth interviews with postpartum women (n = 61) to explore decision-making about contraceptive use after delivery, including facility choice. RESULTS: When seeking contraceptive services, women in this study preferred private over public facilities due to convenience and timeliness of services. Women avoided public facilities due to long waits and disrespectful providers. Study participants reported, however, that they felt more confident about the technical medical quality in public facilities than in private, and believed that private providers prioritized profit over safe medical practice. Women reported that public facilities offered comprehensive counseling and chose these facilities when they needed contraceptive decision-support. Provision of comprehensive counseling and screening, including side effects counseling and management, determined perception of quality. CONCLUSION: Women believed private providers offered the advantages of convenience, efficiency and privacy, though they did not consistently offer high-quality care. Quality-improvement of contraceptive care at private facilities could include technical standardization and accreditation. Development of support and training for side effect management may be an important intervention to improve perceived quality of care.

Women's attitudes towards receiving family planning services from community health workers in rural Western Kenya.

BACKGROUND: Kenya ranks among the countries in Africa with high fertility rates. In order to reverse the trends in high fertility rates, there is need to increase uptake of family planning services particularly by use of community health workers (CHWs) in providing these services in rural areas. OBJECTIVE: To describe the perceptions of women towards family planning service provision by CHWs in four rural districts of Western Kenya. It is based on baseline survey data from a three-year, rural community-based family planning project funded by The David and Lucile Packard Foundation. METHODS: A cross-sectional baseline survey was conducted in Western Kenya. The data presented is part of a broader the broader survey . A survey questionnaire was administered to 1,997 women (15-49 years) but only 963 cases were valid for our analyses. RESULTS: The findings revealed that only a third of the respondents exhibited high approval for Family Planning services from CHWs. Only four out of the thirteen variables explored showed significance on attitudes towards family planning services from CHWs. These are age, level of education, knowledge about family planning benefits and districts. CONCLUSION: Women's perception towards family planning services delivered by CHWs in Western region in Kenya is quite low. To improve the demand and supply for family planning services in this region, there is need to invest a substantial amount of effort into sensitization of women on the relevance of CHWs in providing family planning services.