This work explored perceptions regarding the roles, norms and incentives influencing the performance of Clinical Officers (COs) in rural district hospitals in Kenya. In order to improve access to health care mainly in rural areas, COs are increasingly being used to perform tasks that were previously the preserve of physicians. The assumption underlying their use is that they are a viable option to doctors. Studies have shown with reference to HIV care and obstetric and gynaecological surgical tasks that COs’ performance is comparable to that of physicians. Other studies also show that the care offered by COs is cost effective when compared with the costs associated with physicians and obstetricians care. However, there is emerging work which shows that COs are not happy in their assigned role in the health system. These studies report CO’s dissatisfaction with the low remuneration, poor career progress and limited career options inherent their jobs as compared with those accorded to physicians. As revealed by a systematic review of mid-level worker literature, addressing these issues is at present difficult due to gaps in our understanding of CO functioning. The existence of these gaps is explained by the limited empirical work on COs in general. The aim of this thesis was to address this issue by exploring issues that affect their routine functioning in a typical rural hospital setting going beyond the fact that they are technically competent. To investigate these issues, a conceptual framework was adopted that explores the tension between what institutions demand and what individuals within them feel able to do. Qualitative methods comprising of interviews, participant observation, review of official policy and hospital level documents on COs, and review of hospital statistics were used. A comparative approach was adopted that sought to; (1) examine perceptions regarding influences on the performance of COs from a variety of sources (COs, doctors, nurses, supervisors, hospital managers, policy makers and policy documents); (2) compare perceptions of respondents based in three faith-based hospitals with those in three government facilities; and, (3), explore features of different work settings (outpatient department, specialist clinics and vertically supported clinics) within these hospitals that encouraged good CO performance. Preliminary findings were reported back to respondents in the six study hospitals. Analysis of the data showed three major issues. First, perceptions of CO roles are problematic despite an acknowledgement of the important function performed by COs in the health system. This is revealed by the variety of images regarding their roles that highlights the need for a redefinition of CO roles. An example of this is shown by the inconsistency between their importance as the ‘backbone of the health system’ versus the poor remuneration and career prospects that their position attracts. Second, there were differences in the norms of CO performance that have resulted in variations regarding what is expected of them. While there was much attention paid to norms of performance about technical aspects of work, less attention focussed on non-technical aspects of work. The adoption of a holistic approach to the notion of CO performance is needed that will enable facilities and the system to meet the needs of the CO which should prompt COs to reciprocate by working better. Third was the issue that there were minimal incentives were attached to COs work. In the public sector, there were some incentives but their availability depended on the work settings. For example, while COs in vertical clinics got training their colleagues in the outpatient department had few chances to get training opportunities. Faith-based hospitals did provide performance related bonuses that encouraged health workers to perform better although notably basic salaries in faith-based hospitals were no better than those given in the government sector. However, major incentives such as salary and promotions in the public sector are handled by the central government giving public sector hospital managers little opportunity to utilise such incentive mechanisms. Where hospital managers may have some leeway in implementing actions at the local level to improve performance, for example through improving CO recognition and working conditions, it was observed that public sector managers were generally less engaged in utilising such incentives. Therefore while it is important to consider and address system level factors that influence CO performance such as salaries and promotions, among others, facility managers would also appear to have some scope to improve performance. In discussing these issues, it is becoming clear that the assumption that COs are altruistic and will continue to work flawlessly in their assigned niche presents a naïve view of COs. This thesis shows that COs are also influenced by self–interest and find ways to overcome or work around any perceived barriers to their growth, some of which may work against the institution. This calls for a re-examination of who COs are, what they do and how they should be managed. Ways of resolving the tension that exists between COs and the health institution exist and can be derived from examining the coping mechanisms that COs have adopted to make their lives better. These coping mechanisms show areas that need attention. Further, there should be greater consideration of the important role that facility managers play in mediating and/or modifying system level influences by creating local environments suitable for better staff performance. Underlying all this is the fact that a long term view of COs is needed. The long term view must go beyond the notion of ‘substitute physician’ as Kenya has made huge investments in this cadre over the last 40 years or more and, with other countries, is likely to continue to rely on such a cadre for much clinical care. This thesis therefore concludes with recommendations that seek to address issues identified with the performance of COs in the Kenyan health system focusing on potential hospital level and system level solutions. Also included is a reflection of the relevance of findings for countries similar to Kenya that are currently using or seek to use COs as a physician substitute.

The Kenya Coast is populated by Africans, Arab-descendants, Indians and Europeans. As part of the Indian Ocean trading network, the predominantly Muslim Coast is an unusually rich site for investigating the historical interface of distinct medical systems---Islamic, ayurvedic and indigenous---which gave rise to an ever-evolving situation of 'medical plurality'. / This thesis addresses medical knowledge, practice and authority on the Coast from the mid-nineteenth to mid-twentieth centuries. The Coast is significant because of the variety of populations which inhabit the area, the early development of Muslim institutions for learning, and the Coast's isolation from white settler-dominated central Kenya, which allowed its populations a relative degree of political and social autonomy. / Particularly crucial for the Coast in this period is the intersection of African migration to the cities, the resulting pressures placed upon urban populations, and changes in disease patterns and intensity. This combined with contests over land appropriation among elites form a backdrop to the Colonial State's attempts to provide sanitation and public health to growing urban communities. / Local responses to disease and colonial public health initiatives point to the intersection of multiple medical understandings and practices on the Coast. This thesis explores the continuities of indigenous medical systems, the resulting inability of Western medicine to gain uncontested orthodoxy, and questions the conceptualization of 'traditional medicine' as a static, homogenous system. Interactions within various 'traditional medicines' are explained to show how indigenous healing and therapeutics have drawn on both formal, text-based and informal, experiential medical knowledge; coexisting and, in some periods, converging with external medical authorities. / Nineteenth century Western scientific medicine remained one of a multiplicity of choices available to local populations. Not until the advent of institutionalized Western medicine did Western medical practice become more widely accepted. Africans' encounter with Western science occurred primarily through British colonial attempts to regulate housing and purify the water supply. The impetus to provide better health for East Africans peaked in the 1920s as the British sought to generate a "productive" labour force. It is the reconciliation of economic demands, increasing populations and inadequate medical support that provides the background for the investigation of changing patterns of health and disease.

No description available.

From July to September, 2002 I spent ten weeks in Kenya conducting full-time research on the macroeconomic impact of HIV/AIDS and community action towards combating the epidemic in locations dominated by members of the Luo tribe in Nyanza Province, Kenya. Gathering data from both the Ministry of Health and non-governmental organizations, I sought to identify the causations and impact of the HIV/AIDS epidemic from a holistic framework. Serving as a pilot study for future research and program evaluation, my research primarily focused on four community-based organizations (CBOs) and Ministry of Health offices located in Kisumu, Nyando, Rachuonyo, and Migori Districts. My research objectives were to explore the cultural and economic variables related to the spread of the HIV/AIDS epidemic, identify which sectors of society were negatively impacted by the epidemic, record community action in response to these impacts, investigate obstacles related to implementation of such interventions, and share research and recommendations with the Ministry of Health and CBOs in Nyanza Province in a way that was meaningful and useful to them. Several qualitative and ethnographic methods were utilized. Participant observation was the principal method used and consisted of a wide range of activities. Additionally, I conducted sixteen formal semi-structured interviews, approximately thirty informal unstructured interviews, and one focus group discussion with nine youth. I found that community-based organizations and the Ministry of Health engaged in a wide variety of activities in response to the HIV/AIDS epidemic including providing Home Based Care to the sick and dying through trained community health workers; training individuals in income-generating activities to provide support for the organizations, the infected and affected, and as a means of prevention of new infections; and providing education to the communities at large. The Ministry of Health and non-governmental organizations also engaged in a significant level of collaborative work to assist each other with their programs and ensure there was no duplication of services. Despite considerable organizational efforts by both the governmental and non-profit sectors, these groups faced a number of different obstacles in their mobilization efforts including limited funding, transportation obstacles in visiting HIV/AIDS clients, and difficulties in convincing individuals to change their behaviors. Individuals interviewed cited a number of factors related to the spread of HIV/AIDS including wife inheritance, wife cleansing, poverty, commercial sex work, and distance marriages. Limited access to voluntary counseling and testing (VCT) services was also an obstacle in a number of communities. Additionally, I found a positive association between access to VCT services, perceptions of people living with HIV/AIDS, and social support for the infected. Based on my findings I concluded that individuals' behavior resulting in the transmission of HIV/AIDS is not solely related to lack of knowledge. Circumstances, especially related to poverty, lead to actions such as exchanging sex for money, distance marriages, early marriages for females, and wife inheritance. In order for HIV/AIDS prevalence to be reduced in Kenya, there must be active participation at all levels and from all sectors of society, including from community members themselves, community-based organizations, the Government of Kenya, and international governmental and non-governmental assistance organizations. Among my recommendations I propose the expansion of voluntary counseling and testing services to make it easier for individuals in rural areas to know their HIV status. I also advocate for a holistic and multisectoral response to HIV/AIDS prevention and support for the infected and affected, including through Home Based Care and social support for the infected, support for AIDS orphans, prevention of mother-to-child transmission, effective HIV/AIDS education, reducing poverty through income-generating activities, making school educations accessible for all children, and improving the overall state of health and access to health facilities for all individuals. / Graduation date: 2004

Thesis (Ph.D.)--University of the Witwatersrand, Faculty of Commerce, Law and Management, School of Economic & Business Sciences, November 2016 / Community Health Workers or “CHWs” are often the only link to healthcare for millions of people in the developing world. They are the first point of contact with the formal care system, and represent the most immediate and cost effective way to save lives and improve healthcare outcomes in low-resource contexts. Mobile-health or ‘mHealth’ technologies may have potential to support CHWs at the point-of-care and enhance their performance. Yet, there is a gap in substantive empirical evidence on whether the use of mHealth tools enhances CHW performance, and how their use contributes to enhanced healthcare service delivery, especially in low-resource communities. This is a problem because a lack of such evidence would pose an obstacle to the effective large-scale implementation of mHealth-enabled CHW projects in low-resource settings. This thesis was motivated to address this problem in the Kenyan community health worker context. First, it compared the performance of CHWs using mHealth tools to those using traditional paper-based systems. Second, it developed and tested a replicable Technology-to-Performance Chain (TPC) model linking a set of CHW task and mHealth tool characteristics, to use and user performance outcomes, through four perspectives of Task-Technology Fit (TTF), namely Matching, Moderation, Mediation, and Covariation. A quasi-experimental post-test only research design was adopted to compare performance of CHWs using an mHealth tool to those using traditional paper-based systems. A primary structured questionnaire survey instrument was used to collect data from CHWs operating in the counties of Siaya, Nandi, and Kilifi, who were using an mHealth tool to perform their tasks (n = 257), and from CHWs operating in the counties of Nairobi and Nakuru using traditional paper-based systems to perform their tasks (n = 353). Results showed that CHWs using mHealth tools outperform their counterparts using paper-based systems, as they were observed to spend much less time completing their monitoring, prevention, and referral reports weekly, and report higher percentages of both timeous and complete monthly cases. In addition, mHealth tool users were found to have more positive perceptions of the effects of the technology on their performance, compared to those using traditional paper-based systems. An explanatory, predictive, research design was adopted to empirically assess the effects of a ‘fit’ between the CHW task and mHealth technology (TTF) on use of the mHealth technology and on CHW user performance. TTF was tested from the Matching, Moderation, Mediation, and Covariation ‘fit’ perspectives using the cross-sectional survey data collected from the mHealth tool users (n = 257). Results revealed that there are various unique ways in which a ‘fit’ between the task and technology can have significant impacts on use and user performance. Specifically, results showed that the paired-match of time criticality task and technology characteristics impacts use, while that of time criticality and information dependency task and technology characteristics impacts user performance. Results also showed that the cross-product interaction of mobility task and interdependence technology characteristics impacts use, and that of mobility task and interdependence and information dependency technology characteristics, impacts user performance. Similarly, the cross-product interaction of information dependency task and time criticality technology characteristics impacts user performance. Moreover, results showed that a perceived ‘fit’ between CHW task and mHealth technology characteristics partially and fully mediates the effects of user needs and tool functions on use and user performance, whereas ‘fit’ as an observed pattern of holistic configuration among these task and technology characteristics impacts use and user performance. It was also found that the perfect ‘fit’ between CHW task and mHealth tool technology characteristics leads to the highest levels of use and user performance, while a misfit leads to a decline in use and user performance. Notably, an over-fit of mHealth technology support to the CHW task leads to declining use levels, while an under-fit leads to diminishing user performance. Of the four ‘fit’ perspectives tested, the matching and cross-product interaction of task and technology characteristics offer the most dynamic insights into use and user performance impacts, whereas user-perception and holistic configuration, were also shown to be significant, thus further reinforcing these effects. Tests of a full TPC model revealed that greater mHealth tool use had a positive effect on the effectiveness, efficiency, and quality of CHW performance in the delivery of patient care. Moreover, it was found that ‘facilitating conditions’ and ‘affect toward use’ had positive effects on mHealth tool use. Furthermore, a perceptual TTF was found to have positive effects on mHealth tool use and CHW performance. Of note, this perceived TTF construct was found to be simultaneously a stronger predictor of mHealth tool use than ‘facilitating conditions’ and ‘affect toward use’, and a stronger predictor of CHW performance than mHealth tool use. Consequently, TTF was confirmed as the central construct of the TPC. The findings constitute significant empirical insights into the use of mHealth tools amongst CHWs in low resource settings and the extent to which mHealth contributes to the enhancement of their overall performance in the capture, storage, transmission, and retrieval, of health data as part of their typical workflows. This study has provided much needed evidence of the importance of a ‘fit’ between CHW task and mHealth technology characteristics for enabling mHealth impacts on CHW performance. The study also shows how these inter-linkages could improve the use of mHealth tools and the performance of CHWs in their delivery of healthcare services in low-resource settings, within the Kenyan context. Findings can inform the design of mHealth tools to render more adequate support functions for the most critical CHW user task needs in a developing world context. This study has contributed to the empowerment of CHWs at the point-of-care using mHealth technology-enabled service delivery in low-resource settings, and contributes to the proper and successful ‘scaling-up’ of implemented mHealth projects in the developing world. / MT 2018

The purpose of this study was to describe factors that influence the enrolment of dairy farmers to a Community Health Insurance scheme for better access to healthcare. Quantitative, descriptive, contextual, cross-sectional research was conducted and the Health Insurance for the Poor framework was used to describe these factors. Data collection was done using a structured interview guide. The sample consisted of 135 farmers who supplied milk to a dairy cooperation in western Kenya. Among the sample were respondents (n=17) who were enrolled to the Tanykina Community Healthcare Plan (TCHP). The findings revealed that lack of information and unfamiliarity with TCHP, lack of affordability and the distance from the TCHP centres might prevent farmers from registering for the Tanykina Community Healthcare Plan. Improved marketing strategies and establishing more health centres which are more accessible are among the recommendation made to increase the membership to the TCHP / Health Studies / M.A. (Public Health)

Submitted in fulfillment of the requirements for the degree of Doctor of Philosophy (PhD) Health Science, Durban University of Technology, Durban, South Africa, 2017. / Background: The HIV pandemic has attracted unprecedented scale-up in resources to curb its escalation and manage those afflicted. Although evidence from developing countries suggests that public health systems have been strengthened as a result of scale-up, only anecdotes exist in other countries. Despite scale-up, the prevalence of HIV/AIDS is still high and the resultant mortality and morbidity demands a refocus. Furthermore, the HIV/AIDS epidemic has severely strained vulnerable health systems in developing countries leading to concerns among policy makers about non-HIV priority services. Although anecdotally, it is clear that HIV scale-up has had profound effects on health systems, available evidence does not allow for an assessment of the impact of such effects on health care access, service delivery or medical outcomes for non- HIV conditions. The aim of this study was to determine the impact of HIV/AIDS scale-up on non-HIV priority services in the former Nyanza Province, Kenya. Additionally we determined the benefits and detriments of HIV programmes, and identified the elements of successful HIV programs and their effect on scale-up and last but not least determined the perceptions, attitudes and experiences of health care staff towards scale-up and integration of health care services. The first part of the main sequential study reviewed practices during scale-up by looking at public health facilities within the Province at Nyanza in Kenya. This looked at health management information systems (HMIS) and routine health facility client records for five years, 2009-2013 with a comparison of trends in 2009 to that in 2013. This data was reviewed in order to show trends in delivery of HIV priority and non-HIV services. The second part of the study utilized a prospective cross sectional survey to determine perceptions, attitudes and experiences xi of facility personnel towards HIV/AIDS scale up. Randomly sampled facilities involved in the delivery of any aspects of HIV diagnosis care and treatment were investigated. Self-administered questionnaires and in-depth interviews were used to obtain information on impact of HIV services on non-HIV priority services on health managerial staff in the facilities and key informants who have shaped scale up. We created a qualitative codebook based on three major themes identified from the data: (1) Meaning and importance of HIV scale-up (2) Perspectives of scale-up on service delivery on non-HIV services and (Ministry of State for Planning) Health facility staff awareness. The findings indicate that the interventions that were utilized in the scale-up of HIV in 2009 resulted in significant increases in uptake of the service in 2013 (p<0.01) and total integration of HIV and non-HIV services at all the health facilities thereby contributing to improved health outcomes beyond those specifically addressed by HIV programs. This study has also shown that utilization of both HIV and non-HIV services increased significantly for both years after integrated HIV care was introduced in the health facilities (p<0.01). Notable increases were found for ANC utilization (p=0.09), family planning (p=0.09), screening for tuberculosis and malaria (p<0.01) and provision of support services (p<0.01) to HIV infected people. The scale up of HIV in the region had several human resource policy implications resulting from staff turnover and workload. Stakeholder engagement and sustainability are critical in the sustenance of these initiatives. Strategic alliances between donors, NGOs and the government underpinned the scale-up process. Policies around scale-up and health service delivery were vital in ensuring sustainability of scale- up and service integration. This study has attempted to provide evidence on the impact of HIV scale-up on non-HIV service delivery in three different settings, in two different time periods and it therefore concludes that the evidence is mixed with most of the impact being positive with some aspects that still needs development. It is critical to pursue the integration of HIV and non- HIV services in a strategic and systematic manner so as to maximize the public health impact of these efforts. The proposed model, best practices and practices requiring improvement will be communicated to the relevant ministries to ensure its integration into policy. / D

The purpose of this study was to describe factors that influence the enrolment of dairy farmers to a Community Health Insurance scheme for better access to healthcare. Quantitative, descriptive, contextual, cross-sectional research was conducted and the Health Insurance for the Poor framework was used to describe these factors. Data collection was done using a structured interview guide. The sample consisted of 135 farmers who supplied milk to a dairy cooperation in western Kenya. Among the sample were respondents (n=17) who were enrolled to the Tanykina Community Healthcare Plan (TCHP). The findings revealed that lack of information and unfamiliarity with TCHP, lack of affordability and the distance from the TCHP centres might prevent farmers from registering for the Tanykina Community Healthcare Plan. Improved marketing strategies and establishing more health centres which are more accessible are among the recommendation made to increase the membership to the TCHP / Health Studies / M.A. (Public Health)