International stakeholder perspectives on One Health training and empowerment: a needs assessment for a One Health Workforce Academy.

BACKGROUND: One Health is defined as an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals and ecosystems; this approach attracts stakeholders from multiple sectors, academic disciplines, and professional practices. The diversity of expertise and interest groups is frequently and simultaneously framed as (1) a strength of the One Health approach in the process of understanding and solving complex problems associated with health challenges such as pathogen spillovers and pandemics and (2) a challenge regarding consensus on essential functions of One Health and the sets of knowledge, skills, and perspectives unique to a workforce adopting this approach. Progress in developing competency-based training in One Health has revealed coverage of various topics across fundamental, technical, functional, and integrative domains. Ensuring that employers value the unique characteristics of personnel trained in One Health will likely require demonstration of its usefulness, accreditation, and continuing professional development. These needs led to the conceptual framework of a One Health Workforce Academy (OHWA) for use as a platform to deliver competency-based training and assessment for an accreditable credential in One Health and opportunities for continuing professional development. METHODS: To gather information about the desirability of an OHWA, we conducted a survey of One Health stakeholders. The IRB-approved research protocol used an online tool to collect individual responses to the survey questions. Potential respondents were recruited from partners of One Health University Networks in Africa and Southeast Asia and international respondents outside of these networks. Survey questions collected demographic information, measured existing or projected demand and the relative importance of One Health competencies, and determined the potential benefits and barriers of earning a credential. Respondents were not compensated for participation. RESULTS: Respondents (N = 231) from 24 countries reported differences in their perspectives on the relative importance of competency domains of the One Health approach. More than 90% of the respondents would seek to acquire a competency-based certificate in One Health, and 60% of respondents expected that earning such a credential would be rewarded by employers. Among potential barriers, time and funding were the most cited. CONCLUSION: This study showed strong support from potential stakeholders for a OHWA that hosts competency-based training with opportunities for certification and continuing professional development.

Maternal and child health indicators in primary healthcare facilities: Findings in a health systems quasi-experimental study in western Kenya.

Background and purpose: Maternal and infant mortality are higher in low-income than in high-income countries due to weak health systems. The objective of this study was to improve access, utilization and quality of Maternal and Child Health care through a predesigned Enhanced Health Care System (EHC) that embodies the World Health Organization (WHO) pillars of the health system. Design and methodology: This study was conducted in two dispensaries in the Counties of Busia and Bungoma in Kenya as intervention sites and in four control clusters in Kakamega, Uasin Gishu, Trans Nzoia and Elgeyo Marakwet Counties. The study population was pregnant women and their children delivered over the study period in the intervention and control clusters.A quasi-experimental study design was used to conduct the study between 2015 and 2020 to compare the outcomes of the implementation of the EHC using the Find Link Treat and Retain (FLTR) strategy in one cluster, community owned initiatives in the other cluster and four control clusters at baseline and at the end of the study. A baseline survey was conducted in year one and an end line survey in the fifth year. Continuous data collection on maternal and childhood health indicators was done in all the six clusters and comparison made at the end of the study between the clusters. Results: We found a 26%, 10.3% and 0.8% increase in antenatal care (ANC) attendance in the intervention clusters of Obekai, Kabula and control clusters respectively. There was a 28.2%, 5.8% and 17.0% increase in attendance of 4+ ANC clinics of Obekai, Kabula and control clusters respectively. There was a 24% and 13% increase in Obekai and Kabula respectively in contraceptive use and a 2% decrease in contraceptive use in the control locations. There was a 38.2%, 25.6% and 34.7% increase in facility deliveries over the study period in Obekai, Kabula and control clusters respectively. There was a marked increase in immunization coverage in the intervention clusters of Obekai and Kabula compared to a significant decrease in control clusters for BCG, polio, pentavalent and measles. Conclusions and recommendations: In conclusion, use of the health systems approach in health care provision provides a holistic improvement in access and utilization of health services and in the improvement of health indicators.We do recommend that a systems approach be used in health services delivery to improve access, utilization and quality of health care provision at community and primary care levels.

The right of access to healthcare: an analysis of how legal and institutional frameworks constrain or facilitate access to healthcare for residents in border areas in the East African Community.

BACKGROUND: Despite many countries working hard to attain Universal Health Coverage (UHC) and the Health-related Sustainable Development Goals, access to healthcare services has remained a challenge for communities residing along national borders in the East Africa Community (EAC). Unlike the communities in the interior, those along national borders are more likely to face access barriers and exclusion due to low health investments and inter-state rules for non-citizens. This study explored the legal and institutional frameworks that facilitate or constrain access to healthcare services for communities residing along the national borders in EAC. METHODS: This study is part of a broader research implemented in East Africa (2018-2020), employing mixed methods. For this paper, we report data from a literature review, key informant interviews and sub-national dialogues with officials involved in planning and implementing health and migration services in EAC. The documents reviewed included regional and national treaties, conventions, policies and access rules, regulations and guidelines that affect border crossing and access to healthcare services. These were retrieved from official online and physical libraries and archives. RESULTS: Overall, the existing laws, policies and guidelines at all levels do not explicitly deal with cross border healthcare access especially for border residents, but address citizen rights and entitlements including health within national frameworks. There is no clarity on whether these rights can be enjoyed beyond one's country of citizenship. The review found examples of investments in shared health infrastructure to benefit all EAC member countries - a signal of closer cooperation for specialized health care, this had not been accompanied by access rule for citizens outside the host country. The focus on specialized care is unlikely to contribute to the every-day health care needs of border resident communities in remote areas of EAC. Nevertheless, the establishment of the EAC entail opportunities for increased collaboration and integration beyond the trade and customs union to included health care and other social services. The study established active cooperation aimed at disease surveillance and epidemic control among sub-national officials responsible for health and migration services across borders. Health insurance cards, national identification cards and official travel documents were found to constrain access to health services across the borders in EAC. CONCLUSION: In the era of UHC, there is need to take advantage of the EAC integration to revise legal and policy frameworks to leverage existing investments and facilitate cross-border access to healthcare services for communities residing along EAC borders.

Improving maternal and child health outcomes through a community involvement strategy in Kabula location, Bungoma County, Kenya.

Background: Maternal, fetal and neonatal mortality are higher in low-income compared to high-income countries due to weak health systems including poor access and utilization of health services. Despite enormous recent improvements in maternal, neonatal and under five children health indicators, more rapid progress is needed to meet the targets including the Sustainable Development Goal 3(SDG). In Kenya these indicators are still high and comprehensive systems are needed to attain these goals. Objective: To facilitate innovative partnerships in health care provision and to assess trends in access, utilization and quality of Maternal and Child Health care through the health systems approach using community owned initiatives including use of community owned resourse persons (CORPs), establishment of Community Based Organisations (CBOs) and Income Generating Activities(IGAs). Study site: This was implemented in Kabula location, Bungoma County, Kenya between January 2016 and April 2019. Study population: Pregnant women, newborns and under-five children living in Kabula location identified by Community Owned Resource Persons (CORPs). Methods: A prospective study to show trends in maternal, neonatal and infant outcomes through the implementation of community owned initiatives. Findings: General, under five and antenatal clinic attendance increased four fold in 2016,2017 and 2018. There was a 76% full immunization coverage with 97% BCG and 84% Polio coverage respectively among children studied. There was an 87% facility delivery rate among the pregnant women enrolled in the study. Conclusions: Trends in Maternal and under-five health indicators in Kabula showed improvements over the study period following the implementation of the community owned initiatives and community participation. Recommendations: The community owned initiatives as implemented in this study is useful in primary care and universal health coverage programs in health care delivery systems in LMICs.

Experiences of seeking healthcare across the border: lessons to inform upstream policies and system developments on cross-border health in East Africa.

OBJECTIVES: This study explored the experiences of accessing care across the border in East Africa. PARTICIPANTS: From February to June 2018, a cross-sectional study using qualitative and quantitative methods was conducted among 279 household adults residing along selected national border sites of Uganda, Kenya and Rwanda and had accessed care from the opposite side of the border 5 years prior to this study. SETTING: Access to HIV treatment, maternal delivery and childhood immunisation services was explored. We applied the health access framework and an appreciative inquiry approach to identify factors that enabled access to the services. MEASURES: Exploratory factor analysis and linear regression were used for quantitative data, while deductive content analysis was done for the qualitative data on respondent's experiences navigating health access barriers. RESULTS: The majority of respondents (83.9%; 234/279) had accessed care from public health facilities. Nearly one-third (77/279) had sought care across the border more than a year ago and 22.9% (64/279) less than a month ago. From the linear regression, the main predictor for ease of access for healthcare were ''ease of border crossing' (regression coefficient (RegCoef) 0.381); 'services being free' (RegCoef 0.478); 'services and medicines availability' (RegCoef 0.274) and 'acceptable quality of services' (RegCoef 0.364). The key facilitators for successful navigation of access barriers were related to the presence of informal routes, speaking a similar language and the ability to pay for the services. CONCLUSION: Communities resident near national borders were able to cross borders to seek healthcare. There is need for a policy environment to enable East Africa invest better and realise synergies for these communities. This will advance Universal Health Coverage goals for communities along the border who represent the far fang areas of the health system with multiple barriers to healthcare access.

Community participation in the collaborative governance of primary health care facilities, Uasin Gishu County, Kenya.

INTRODUCTION: Community participation in the governance of health services is an important component in engaging stakeholders (patients, public and partners) in decision-making and related activities in health care. Community participation is assumed to contribute to quality improvement and goal attainment but remains elusive. We examined the implementation of community participation, through collaborative governance in primary health care facilities in Uasin Gishu County, Western Kenya, under the policy of devolved governance of 2013. METHODS: Utilizing a multiple case study methodology, five primary health care facilities were purposively selected. Study participants were individuals involved in the collaborative governance of primary health care facilities (from health service providers and community members), including in decision-making, management, oversight, service provision and problem solving. Data were collected through document review, key informant interviews and observations undertaken from 2017 to 2018. Audio recording, notetaking and a reflective journal aided data collection. Data were transcribed, cleaned, coded and analysed iteratively into emerging themes using a governance attributes framework. FINDINGS: A total of 60 participants representing individual service providers and community members participated in interviews and observations. The minutes of all meetings of five primary health care facilities were reviewed for three years (2014-2016) and eight health facility committee meetings were observed. Findings indicate that in some cases, structures for collaborative community engagement exist but functioning is ineffective for a number of reasons. Health facility committee meetings were most frequent when there were project funds, with discussions focusing mainly on construction projects as opposed to the day-to-day functioning of the facility. Committee members with the strongest influence and power had political connections or were retired government workers. There were no formal mechanisms for stakeholder forums and how these worked were unclear. Drug stock outs, funding delays and unclear operational guidelines affected collaborative governance performance. CONCLUSION: Implementing collaborative governance effectively requires that the scope of focus for collaboration include both specific projects and the routine functioning of the primary health care facility by the health facility committee. In the study area, structures are required to manage effective stakeholder engagement.

A system approach to improving maternal and child health care delivery in Kenyan communities and primary care facilities: baseline survey on maternal health.

BACKGROUND: Maternal, fetal and neonatal mortality are 10 to 100 fold higher in many low-income compared to high-income countries. Reasons for these discrepancies include limited antenatal care and delivery outside health facilities. OBJECTIVES: The study aimed at conducting a baseline survey to assess the current levels of maternal health indicators in six counties in Western Kenya. METHODS: This was a cross sectional study conducted targeting women residing in Uasin-Gishu, ElgeyoMarakwet, TransNzoia, Bungoma, Busia and Kakamega counties who had given birth five years prior to the interview. Socio-demographic and maternal indicators were collected using forms adopted from KDHS 2009. Interviews were conducted in the homesteads between December 2015 and June 2016. RESULTS: A total of 6257 women participated in the study, median age 27 years IQR 23-32. Majority of the women had post-primary level of education, were married and 40% were members of an income-generating activity. 56.8% were using modern family planning method, 49% attended WHO recommended four plus antenatal clinic visits and only 20% attended in the first trimester. Majority, 85% had their most recent delivery in a health facility. CONCLUSION: Findings suggest that women are not attending recommended four plus antenatal clinic visits and even those that attend are few are during the first trimester.

If you can't measure it- you can't change it - a longitudinal study on improving quality of care in hospitals and health centers in rural Kenya.

BACKGROUND: The Kenyan Ministry of Health- Department of Standards and Regulations sought to operationalize the Kenya Quality Assurance Model for Health. To this end an integrated quality management system based on validated indicators derived from the Kenya Quality Model for Health (KQMH) was developed and adapted to the area of Reproductive and Maternal and Neonatal Health, implemented and analysed. METHODS: An integrated quality management (QM) approach was developed based on European Practice Assessment (EPA) modified to the Kenyan context. It relies on a multi-perspective, multifaceted and repeated indicator based assessment, covering the 6 World Health Organization (WHO) building blocks. The adaptation process made use of a ten step modified RAND/UCLA appropriateness Method. To measure the 303 structure, process, outcome indicators five data collection tools were developed: surveys for patients and staff, a self-assessment, facilitator assessment, a manager interview guide. The assessment process was supported by a specially developed software (VISOTOOL®) that allows detailed feedback to facility staff, benchmarking and facilitates improvement plans. A longitudinal study design was used with 10 facilities (6 hospitals; 4 Health centers) selected out of 36 applications. Data was summarized using means and standard deviations (SDs). Categorical data was presented as frequency counts and percentages. RESULTS: A baseline assessment (T1) was carried out, a reassessment (T2) after 1.5 years. Results from the first and second assessment after a relatively short period of 1.5 years of improvement activities are striking, in particular in the domain 'Quality and Safety' (20.02%; p < 0.0001) with the dimensions: use of clinical guidelines (34,18%; p < 0.0336); Infection control (23,61%; p < 0.0001). Marked improvements were found in the domains 'Clinical Care' (10.08%; p = 0.0108), 'Management' (13.10%: p < 0.0001), 'Interface In/out-patients' (13.87%; p = 0.0246), and in total (14.64%; p < 0.0001). Exemplarily drilling down the domain 'clinical care' significant improvements were observed in the dimensions 'Antenatal care' (26.84%; p = 0.0059) and 'Survivors of gender-based violence' (11.20%; p = 0.0092). The least marked changes or even a -not significant- decline of some was found in the dimensions 'delivery' and 'postnatal care'. CONCLUSIONS: This comprehensive quality improvement approach breathes life into the process of collecting data for indicators and creates ownership among users and providers of health services. It offers a reflection on the relevance of evidence-based quality improvement for health system strengthening and has the potential to lay a solid ground for further certification and accreditation.

The Implementation of Governance Attributes in Health in Uasin Gishu County, Kenya.

BACKGROUND: Globally, good governance is increasingly recognised as an important factor in health systems. Governance is a key determinant of performance, particularly towards achieving targets that ultimately affect economic and social development. However, conceptually and practically, governance is poorly understood by decision makers at various levels. Governance is also difficult to measure, but it is critical in assessing responsive, inclusive, effective, and efficient services. We examined the extent to which governance attributes have been implemented within the Department of Health in Uasin Gishu County, Kenya. METHODS: A cross-sectional research design was adopted, with 108 decision makers forming the target population. The study period was between April and July 2016. Select documents relating to governance were reviewed; subsequently, data were collected using a self-administered, semi-structured questionnaire, with 5-point Likert-type questions and open-ended questions. We calculated proportions related to agreement levels to establish the decision makers' perceptions on the implementation of governance attributes. Cronbach's α for the items was between 0.72 and 0.84. Qualitative data were coded and categorised using a framework approach. RESULTS: Of the 93 decision makers who responded, most (n=64, 68.8%) had been in their current position for less than 5 years. Regarding governance attributes, over half of the participants agreed on the implementation of good governance in terms of strategic vision as well as regulation and oversight. Around half of the participants were undecided on the implementation of good governance in terms of intelligence and information, transparency, participation, and consensus orientation. Almost two-thirds believed that accountability and equity were poorly implemented. A minority rated the overall governance score as good, while two-thirds considered governance to be poor. Corruption, nepotism, lack of transparency, political interference, and inadequate use of information were all reported to affect the implementation of good governance. CONCLUSION: Decision makers reported poor implementation of governance attributes at public health facilities, especially in terms of accountability, equity, community participation, consensus orientation, strategic vision, and regulation and oversight. It is feasible and critical to evaluate implementation of governance attributes to help improve governance; the successful implementation of each attribute depends on the successful implementation of all others.

A system approach to improving maternal and child health care delivery in Kenya: innovations at the community and primary care facilities (a protocol).

BACKGROUND: Maternal, fetal and neonatal mortality are higher in low-income compared to high-income countries due to weak health systems including poor access and utilization of health services. Despite enormous recent improvements in maternal, neonatal and under 5 health indicators, more rapid progress is needed to meet the targets including the Development Goal 3(SDG). In Kenya these indicators are still high and comprehensive systems are needed to attain the targets of the SDG 3 by 2030. We describe the structure and methods of a study to assess the impact of an innovative system approach on maternal, neonatal and under-five children outcomes. This will be implemented in two clusters in the Counties of Busia and Bungoma in Kenya. There will be 4 control clusters in Kakamega, UasinGishu, Trans Nzoia and Elgeyo Marakwet Counties in Kenya. The study population will be pregnant women, newborns and under-five children identified over the study period. The objective of the study is to improve access, utilization and quality of Maternal and Child Health care through a predesigned Enhanced Health Care System (EHC) that embodies six WHO pillars of the health system and community owned initiatives including Community Based Organisations and Income Generating Activities. METHODS/DESIGN: A five year quasi-experimental design will be used to compare the outcomes of the implementation of the EHC using the Find Link Treat and retain (FLTR) strategy in one cluster, community owned initiatives in one cluster and four control clusters at baseline and at the end of the study. A Baseline survey will be conducted in year one and an endline in the fifth year in which maternal, neonatal and underfive childhood outcomes will be compared. DISCUSSION: The expected findings from the study include showing trends in improvement in the intervention clusters for morbidity, mortality, health service utilization and access indicators. Use of the health systems approach in health care provision is expected to provide a holistic improvement in the quality of care in the study populations in the intervention clusters that will lead to improved health indicators including morbidity and mortality. It is expected that the findings will inform health policy of the national and county governments in Kenya and worldwide.