Wednesday, June 12, 2019

PERFORMANCE OF PUBLIC HOSPITALS IN KENYA: DOES MANAGEMENT MATTER?

Francis Kimani Mwihia  
Registration Number W80/85341/2012


ABSTRACT


Background: Management is as old as human civilization and sprung out of necessity to satisfy both individual and communities with basic requirements such as food, cloth, shelter, and security. It is a critical administrative role in ensuring progress in any organization. It is a decision making role aimed at providing strategic leadership for an organization (Black, et. al., 2009) towards the achievement of a set of goals. Like any other organization, hospitals also require proper management coupled with good management practices to ensure high performance with regards to quality and volume (quantity) of healthcare delivery. However, in Kenya after many successive government policies implemented such as free healthcare access, devolution of hospital management etc, all targeting at improving public healthcare delivery over the years, health sector performance especially within the public sector still remains below expectation (MoH, 2014). There still exists high level of inequality in healthcare access both geographically and economically, public health sector workers working part-time in private hospitals (Moonlighting), inadequate human resources, lack of qualified health workers, low morale, poor staff attitude, weak supervision, inefficient use of resources etc. The core of this situation always appears to be management yet many of the policies implemented to improve the health system were directed towards management, thus making it proficient to reassess the role of management in healthcare delivery in Kenya. Against this backdrop, coupled with inadequate literature specific to Kenya, the study purposed to address the question of whether management matters in healthcare delivery, specifically with respect to hospitals. It purposed to address this question through the following specific objectives; to identify key hospital management practices in government owned hospitals in Kenya; to investigate the nexus between hospital management practices and the quantity and quality of healthcare delivery and to analyze the effect of hospital management on the efficiency and health outputs of hospitals in Kenya.
Methods: The study employed cross sectional research design where both qualitative and quantitative data were collected from all the 25 hospitals in central Kenya.  The study collected data from samples of hospital managers and patients. The patients sample sizes were computed using Fisher’s method and random sampling method was used in selection of patients where the data was entered into the computer using research electronic data capture (Red Cap) device. In addition, qualitative data about performance of hospitals were collected using key informant and focus group. The data was collected through the administration of questionnaires, interviews, DEA efficiency estimating method coupled with OLS and Tobit estimation techniques were used to analyze the data which was also presented in form of tables and charts.
Results: The study found out that the most popular management practice in the study area was regular supervision, practiced by 99% of the managers, followed by effective communication, practiced by 88%; good relation with others, practiced by 81%; and consultation and consensus building, practiced by 70%. The findings also revealed that 17 (68%) of the hospitals had good management, whereas 13 (52%) were technically efficient and hospitals with good management practice is 2.4 times extra likely to be technically efficient compared to hospitals with poor management practice. Most of the management practices had a statistically significant direct effect on the quantity or volume of hospital service. Moreover, strong associations between quality indicators and management practices were evident from the data. In particular, work plan, work plan implementation, effective communication and overall management index were positively associated with the reduction in emergency waiting time for the Caesarian section.
Conclusions: The study concludes that good management when applied to hospitals results in improved hospital outputs and outcomes. The study concludes that management practices in Kenyan public hospitals are strongly and positively associated with hospital performance (quality and quantity of the services offered), and with the health outcomes of communities. It has also been shown that hospital efficiency levels are generally high, with 19(76%) out of 25 hospitals ranging from 73.2% to 100%.        
Recommendations: The study recommends that government (MoH) should make policies that ensure that the three top hospital managers;  the medical superintendent, nursing officer and the administrator ) resides within the hospital compound, increase competition among hospitals of a similar category, hospital managers and prospective managers be sensitized and trained in various management practices, continuous monitoring and evaluation on management standards and hospital performance and entrenchment of management practices such as daily supervision, staff empowerment, the delegation of duties and motivation. Finally, it recommends that further study ought to be carried out to investigate how managers’ residence affects hospital performance.
 

Monday, June 3, 2019

TIME-TO-EVENT ANALYSIS OF EFFECTIVENESS OF HIV POST-EXPOSURE PROPHYLAXIS IN A NAIROBI SEX WORKERS COHORT


Research Project by Jane Musimbi Evelia
W62/88856/2016
University of Nairobi

ABSTRACT
Background: The current overall HIV prevalence in Kenya is 4.8%, yet research on effectiveness of non-occupational Post-Exposure Prophylaxis (PEP) for HIV prevention is still patchy and consequent risks poorly understood.
Objective: To characterize the PEP real-world effectiveness and prospective sexual health risks among.
Methods: Data from sex workers aged ≥18 years prescribed PEP as from 2016 to 15th October 2018 were analyzed. A comparison group of non-PEP/non-Pre-Exposure Prophylaxis (PrEP) enrolled as from 2016 was used and random sample of 503 taken for comparative analysis in a ratio of 1:1. Socio - demographic comparison of profiles was done at baseline using a Chi-squared test. Kaplan-Meier cumulative event and hazard functions and Cox proportional hazards models were fitted, in analyses that included PrEP, for time-to-ARV initiation. Results: There were 42.9% of 196 PEP users and 57.1% (comparison group) whose data were linked with baseline data. Chi-square test for differences resulted in statistical significance in age categories (p=0.0027) and in sex work duration (p<0.001) between the PEP and the Comparison group. There were 8 (0.64%) total HIV infections (ARV initiations), 6 (1.3%) from the Control group and 2 (0.64%) from Pre-Exposure Prophylaxis (PrEP) group. Five (3.1%) incident HIV-infection/ARV initiation among MSMW and 3 (0.28%) among FSW found. Men who have sex with men (MSMW) were at higher risk of HIV compared to female sex workers (FSW) with hazard ratio of 17.2 (p<0.00001). In total 52 (9.35%) sex workers had repeat PEP prescriptions with 90.3%, 8.4%, 1.1% and 0.2% having had 1,2,3 and 4 PEP episodes respectively. PEP recurrence rate was 8.6 per 100 person-months of follow up. There was HIV event-free survival in the PEP group. Univariable and multivariable Cox models yielded same results. Multiple pairwise log-rank test indicated presence of significant survival difference between PEP and Controls (p-value=0.046), insignificant differences between PEP and PrEP (p=0.025) and PrEP and Control group (p=0.631) and evidence of clinically significant results. Survival among PEP users was comparative better hence effective but not statistically significant at alpha 0.05.
Conclusions: There is evidence that PEP is effective when adherently taken and associated with event-free survival but this is not statistically significant. The underpin the potential need to scale up condom counseling and in formulating personalized risk scores for treatment as HIV prevention among the sex workers for behavioural risk change and more focus on MSM.

Friday, May 31, 2019

PRE-CLINICAL CARE, CLINICAL MANAGEMENT AND OUTCOMES OF DOG BITE INJURIES IN HIGH RABIES BURDEN DISTRICTS OF WAKISO AND KAMPALA, UGANDA


PhD Thesis Proposal by Dr. Stevens M. B. Kisaka
W80/52986/2018
University of Nairobi

ABSTRACT

Introduction: There is a rise in dog bites in Uganda. These may result into stigma, morbidity and death. However, the actual burden in the community is not known since all victims do not report to health facilities. In addition, adherence to pre-clinical and clinical guidelines of managing dog bites
are not well known. Furthermore, the bioburden of these injuries and treatment outcomes have not been well assessed.

Objectives: To assess the community burden, pre-clinical care practices and clinical management for dog bite injuries as well as their bearing on the bioburden and outcomes in high rabies burden districts of Wakiso and Kampala in Uganda.

Methods: The community incidence will be determined in households of 2 sub counties of Kawempe (Kampala district) and Nansana Town Council (Wakiso district) for a period of 3 years using an ambi-directional study design. Incidence will be expressed per 10,000 population and defined using descriptive statistics, spatial analysis and spot maps. In both Entebbe and Mulago Hospitals, 360 patients reporting for post-exposure prophylaxis and treatment for dog bite injuries will be interviewed for practices undertaken before presentation to the health facility. Association between adherence to guidelines and associated factors will be determined using logistic regression
with Odds ratios (OR: 95% CI). In addition, health worker practices for treating dog bites will be assessed qualitatively using observations, review of medical records and in-depth interviews with those managing dog bites. Grade II and III wounds will be aseptically swabbed and culture anaerobic
and aerobically for bacterial growth. Bacterial strain identification will be by colony, biochemical characteristics and Matrix Assisted Laser Desorption Time of Flight Mass Spectrometry. Antimicrobial susceptibility testing will be done using Epsilometer test against Metronidazole, methicillin, amoxicillin, doxycycline and cotrimoxazole. The findings will be interpreted using
Guidelines by European Committee on Antimicrobial Susceptibility Testing and analyzed by descriptive and inferential statistics. Lastly, predictors for infection will be determined using a prospective study among the 360 patients who will be followed up for 6 months. Stratified analysis, inferential statistics using logistic regression (RR: 95% CI); Descriptive statistics and Survival analysis: Kaplan meier curves and using Cox regression will be used to assess infection, healing and other outcomes. 

Expected outcomes: Community incidence of dog bite injuries within a 3-year period; factors associated with pre-clinical practices for dog bites; adherence to clinical practices by health care providers; antimicrobial resistance associated with management of dog bites; and predictors of outcomes of dog bite management.

Key words: dog bite, risk factor, antimicrobial resistance, post-exposure prophylaxis, pre-treatment, clinical, practices, outcomes.

Monday, May 27, 2019

ADHERENCE TO CLINICAL GUIDELINES IN THE MANAGEMENT OF DIARRHOEA DISEASES IN CHILDREN AGED BELOW FIVE YEARS ADMITTED AT MAMA LUCY HOSPITAL, NAIROBI


Postgraduate Diploma Research Project by Catherine Wangu Shitemi
W61/8791/2016
University of Nairobi

ABSTRACT
Background: Antimicrobial Resistance has been described as a public health emergency. Antimicrobial stewardship programs have been recommended as one of the ways of combating AMR. Stewardship Programs have been implemented and studied in many parts of the world. We found no studies in literature documenting antimicrobial stewardship in Kenya. 
Objective: The study sought to identify existing antimicrobial stewardship guidelines in Kenya; and to appraise antimicrobial stewardship at Mbagathi County Referral Hospital in Nairobi City County, Kenya.

Methodology: This was a cross-sectional mixed methods survey conducted among health practitioners who prescribe, dispense or administer antimicrobials at the Mbagathi County Referral Hospital. It included a preliminary quantitative followed by a qualitative phase. A self-administered questionnaire was used to collect quantitative data. Qualitative data was collected through key informant interviews.
Descriptive data analysis was done. Variables were analyzed using counts and percentages and results presented using tables and graphs. Audio records of the interviews were transcribed. The data was analyzed using the content analysis approach. Codes were identified and extracted from the transcripts.
The codes were used to build themes on the respondents' views on guidelines, stewardship practices, challenges and opportunities for antimicrobial stewardship.
Results: A total of 171 respondents filled the questionnaire from the 242 that were distributed. Standard documentation of antibiotic prescriptions in patient charts was the most widely used stewardship activity at Mbagathi County Referral Hospital.
Conclusion and recommendations: We found no formal stewardship structure or local policy document available to guide antimicrobial use at the facility. Challenges to be addressed include laboratory capacity for microbiological diagnosis, drug supply and training. We recommend the establishment of an antimicrobial stewardship team to spearhead antimicrobial stewardship at Mbagathi County Referral Hospital.