Policies for type 2 diabetes and non-communicable disease management during the COVID-19 pandemic in Kenya and Tanzania: a desk review and views of decision-makers.

BACKGROUND: The COVID-19 pandemic caused disruptions in care that adversely affected the management of non-communicable diseases (NCDs) globally. Countries have responded in various ways to support people with NCDs during the pandemic. This study aimed to identify policy gaps, if any, in the management of NCDs, particularly diabetes, during COVID-19 in Kenya and Tanzania to inform recommendations for priority actions for NCD management during any future similar crises. METHODS: We undertook a desk review of pre-existing and newly developed national frameworks, policy models and guidelines for addressing NCDs including type 2 diabetes. This was followed by 13 key informant interviews with stakeholders involved in NCD decision-making: six in Kenya and seven in Tanzania. Thematic analysis was used to analyse the documents. RESULTS: Seventeen guidance documents were identified (Kenya=10; Tanzania=7). These included pre-existing and/or updated policies/strategic plans, guidelines, a letter, a policy brief and a report. Neither country had comprehensive policies/guidelines to ensure continuity of NCD care before the COVID-19 pandemic. However, efforts were made to update pre-existing documents and several more were developed during the pandemic to guide NCD care. Some measures were put in place during the COVID-19 period to ensure continuity of care for patients with NCDs such as longer supply of medicines. Inadequate attention was given to monitoring and evaluation and implementation issues. CONCLUSION: Kenya and Tanzania developed and updated some policies/guidelines to include continuity of care in emergencies. However, there were gaps in the documents and between policy/guideline documents and practice. Health systems need to establish disaster preparedness plans that integrate attention to NCD care to enable them to better handle severe disruptions caused by emergencies such as pandemics. Such guidance needs to include contingency planning to enable adequate resources for NCD care and must also address evaluation of implementation effectiveness.

Prevalence and factors associated with caesarean section in Rwanda: a trend analysis of Rwanda demographic and health survey 2000 to 2019-20.

BACKGROUND: Caesarean section (CS) is an important medical intervention for reducing the risk of poor perinatal outcomes. However, CS trends in sub-Saharan Africa (SSA) continue to increase yet maternal and neonatal mortality and morbidity remain high. Rwanda, like many other countries in SSA, has shown an increasing trend in the use of CS. This study assessed the trends and factors associated with CS delivery in Rwanda over the past two decades. METHODS: We used nationally representative child datasets from the Rwanda Demographic and Health Survey 2000 to 2019-20. All births in the preceding 3 years to the survey were assessed for the mode of delivery. The participants' characteristics, trends and the prevalence of CS were analysed using frequencies and percentages. Unadjusted and adjusted logistic regression analyses were used to assess the factors associated with population and hospital-based CS in Rwanda for each of the surveys. RESULTS: The population-based rate of CS in Rwanda significantly increased from 2.2% (95% CI 1.8-2.6) in 2000 to 15.6% (95% CI 13.9-16.5) in 2019-20. Despite increasing in all health facilities over time, the rate of CS was about four times higher in private (60.6%) compared to public health facilities (15.4%) in 2019-20. The rates and odds of CS were disproportionately high among women of high socioeconomic groups, those who resided in Kigali city, had multiple pregnancies, and attended at least four antenatal care visits while the odds of CS were significantly lower among multiparous women and those who had female babies. CONCLUSION: Over the past two decades, the rate of CS use in Rwanda increased significantly at health facility and population level with high regional and socio-economic disparities. There is a need to examine the disparities in CS trends and developing tailored policy guidelines to ensure proper use of CS in Rwanda.

Demand and supply-side barriers and opportunities to enhance access to healthcare for urban poor populations in Kenya: a qualitative study.

OBJECTIVE: To explore the barriers to and options for improving access to quality healthcare for the urban poor in Nairobi, Kenya. DESIGN AND PARTICIPANTS: This was a qualitative approach. In-depth interviews (n=12), focus group discussions with community members (n=12) and key informant interviews with health providers and policymakers (n=25) were conducted between August 2019 and September 2020. Four feedback and validation workshops were held in December 2019 and April-June 2021. SETTING: Korogocho and Viwandani urban slums in Nairobi, Kenya. RESULTS: The socioe-conomic status of individuals and their families, such as poverty and lack of health insurance, interact with community-level factors like poor infrastructure, limited availability of health facilities and insecurity; and health system factors such as limited facility opening hours, health providers' attitudes and skills and limited public health resources to limit healthcare access and perpetuate health inequities. Limited involvement in decision-making processes by service providers and other key stakeholders was identified as a major challenge with significant implications on how limited health system resources are managed. CONCLUSION: Despite many targeted interventions to improve the health and well-being of the urban poor, slum residents are still unable to obtain quality healthcare because of persistent and new barriers due to the COVID-19 pandemic. In a devolved health system, paying attention to health services managers' abilities to assess and respond to population health needs is vital. The limited use of existing accountability mechanisms requires attention to ensure that the mechanisms enhance, rather than limit, access to health services for the urban slum residents. The uniqueness of poor urban settings also requires in-depth and focused attention to social determinants of health within these contexts. To address individual, community and system-level barriers to quality healthcare in this and related settings and expand access to health services for all, multisectoral strategies tailored to each population group are needed.

Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya.

BACKGROUND: Access to primary healthcare is crucial for the delivery of Kenya's universal health coverage policy. However, disparities in healthcare have proved to be the biggest challenge for implementing primary care in poor-urban resource settings. In this study, we assessed the level of access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya. METHODS: The data were drawn from the Lown scholars' study of 300 randomly selected households in Viwandani slums (Nairobi, Kenya), between June and July 2018. Access to primary care was measured using Penchansky and Thomas' model. Access index was constructed using principal component analysis and recorded into tertiles with categories labeled as poor, moderate, and highest. Generalized ordinal logistic regression analysis was used to determine the factors associated with access to primary care. The adjusted odds ratios (AOR) and 95% confidence intervals were used to interpret the strength of associations. RESULTS: The odds of being in the highest access tertile versus the combined categories of lowest and moderate access tertile were three times higher for males than female-headed households (AOR 3.05 [95% CI 1.47-6.37]; p < .05). Households with an average quarterly out-of-pocket healthcare expenditure of ≥USD 30 had significantly lower odds of being in the highest versus combined categories of lowest and moderate access tertile compared to those spending ≤ USD 5 (AOR 0.36 [95% CI 0.18-0.74]; p < .05). Households that sought primary care from private facilities had significantly higher odds of being in the highest versus combined categories of lowest and moderate access tertiles compared to those who sought care from public facilities (AOR 6.64 [95% CI 3.67-12.01]; p < .001). CONCLUSION: In Nairobi slums in Kenya, living in a female-headed household, seeking care from a public facility, and paying out-of-pocket for healthcare are significantly associated with low access to primary care. Therefore, the design of the UHC program in this setting should prioritize quality improvement in public health facilities and focus on policies that encourage economic empowerment of female-headed households to improve access to primary healthcare.

Persistent barriers to the use of maternal, newborn and child health services in Garissa sub-county, Kenya: a qualitative study.

BACKGROUND: North Eastern Kenya has persistently had poor maternal, new-born and child health (MNCH) indicators. Barriers to access and utilisation of MNCH services are structural, individual and community-level factors rooted in sociocultural norms. A package of interventions was designed and implemented in Garissa sub-County aimed at creating demand for services. Community Health Volunteers (CHVs) were trained to generate demand for and facilitate access to MNCH care in communities, while health care providers were trained on providing culturally acceptable and sensitive services. Minor structural improvements were made in the control areas of two facilities to absorb the demand created. Community leaders and other social actors were engaged as influencers for demand creation as well as to hold service providers accountable. This qualitative research was part of a larger mixed methods study and only the qualitative results are presented. In this paper, we explore the barriers to health care seeking that were deemed persistent by the end of the intervention period following a similar assessment at baseline. METHODS: An exploratory qualitative research design with participatory approach was undertaken as part of an impact evaluation of an innovation project in three sites (two interventions and one control). Semi-structured interviews were conducted with women who had given birth during the intervention period. Focus group discussions were conducted among the wider community members and key informant interviews among healthcare managers and other stakeholders. Participants were purposively selected. Data were analysed using content analysis by reading through transcripts. Interview data from different sources on a single event were triangulated to increase the internal validity and analysis of multiple cases strengthened external validity. RESULTS: Three themes were pre-established: 1) barriers and solutions to MNCH use at the community and health system level; 2) perceptions about women delivering in health facilities and 3) community/social norms on using health facilities. Generally, participants reported satisfaction with services offered in the intervention health facilities and many indicated that they would use the services again. There were notable differences between the intervention and control site in attitudes towards use of services (skilled birth attendance, postnatal care). Despite the apparent improvements, there still exist barriers to MNCH services use. Persistent barriers identified were gender of service provider, insecurity, poverty, lack of transport, distance from health facilities, lack of information, absence of staff especially at night-time and quality of maternity care. CONCLUSION: Attitudes towards MNCH services are generally positive, however some barriers still hinder utilization. The County health department and community leaders need to sustain the momentum gained by ensuring that service access and quality challenges are continually addressed.