ObjectiveTo identify factors that have contributed to the systematic development of the Cambodian human resources for health (HRH) system with a focus on midwifery services in response to high maternal mortality in fragile resource-constrained countries.DesignQualitative case study. Review of the published and grey literature and in-depth interviews with key informants and stakeholders using an HRH system conceptual framework developed by the authors (‘House Model’; Fujita et al, 2011). Interviews focused on the perceptions of respondents regarding their contributions to strengthening midwifery services and the other external influences which may have influenced the HRH system and reduction in the maternal mortality ratio (MMR).SettingThree rounds of interviews were conducted with senior and mid-level managers of the Ministries of Health (MoH) and Education, educational institutes and development partners.ParticipantsA total of 49 interviewees, who were identified through a snowball sampling technique.Main outcome measuresScaling up the availability of 24 h maternal health services at all health centres contributing to MMR reduction.ResultsThe incremental development of the Cambodian HRH system since 2005 focused on the production, deployment and retention of midwives in rural areas as part of a systematic strategy to reduce maternal mortality. The improved availability and access to midwifery services contributed to significant MMR reduction. Other contributing factors included improved mechanisms for decision-making and implementation; political commitment backed up with necessary resources; leadership from the top along with a growing capacity of mid-level managers; increased MoH capacity to plan and coordinate; and supportive development partners in the context of a conducive external environment.ConclusionsLessons from this case study point to the importance of a systemic and comprehensive approach to health and HRH system strengthening and of ongoing capacity enhancement and leadership development to ensure effective planning, implementation and monitoring of HRH policies and strategies.
Objective:To investigate key risk factors associated with undernutrition in the first few years of life.Design:A cross-sectional household survey was conducted in January 2018 collecting anthropometric data and other information on household, caregiver and child characteristics. Crude and adjusted odds ratios were calculated to assess the association of these characteristics with stunting and underweight outcomes.Setting:Kitui and Machakos counties in south-east Kenya.Participants:Caregivers and their children aged 0–23 months in 967 beneficiary households of the Government of Kenya’s cash for orphans and vulnerable children (CT-OVC) social protection scheme.Results:Twenty-three per cent of the 1004 children with anthropometric data were stunted, 10 % were underweight and 6 % experienced wasting. The strongest predictors of stunting and underweight were being in the second year of life and being born with a low birth weight. Residing in a poor household and having more than one child under 2 years of age in the household were also significant risk factors for being underweight. Although 43 % of children did not receive the minimal acceptable diet, this was not a significant factor associated with undernutrition. When age was removed as a covariate in children aged 12–23 months, being male resulted in a significantly higher risk of being stunted.Conclusions:While only 9 % of children were born with a low birth weight, these were four to five times more likely to be stunted and underweight, suggesting that preventive measures during pregnancy could have significant nutrition and health benefits for young children in this study area.
IntroductionIn Kenya’s Kitui County, 46% of children under 5 years are stunted. Sanitation and nutrition programmes have sought to reduce child undernutrition, though they are typically implemented separately. We evaluate the effectiveness of an integrated sanitation and nutrition (SanNut) intervention in improving caregiver sanitation and nutrition knowledge and behaviours.MethodsWe conducted a cluster-randomised controlled trial to evaluate the impact of the SanNut intervention on caregiver knowledge, sanitary and hygiene practices, sanitation outcomes and nutrition outcomes. The evaluation included caregivers of children under 5 years across 604 villages in Kitui County. 309 treatment villages were randomly assigned to receive both the SanNut intervention and the standard Community-Led Total Sanitation (CLTS) intervention, while 295 control villages only received the CLTS intervention. 8 households with children under 5 years were randomly selected from each evaluation village to participate in the endline survey, for a total of 4322 households.ResultsSanNut led to modest improvements in sanitary knowledge and practices emphasised by the programme. Caregivers in treatment villages were 3.3 pp (+32%) more likely to mention lack of handwashing after handling child faeces as a potential cause of diarrhoea, and 4.9 pp (+7.8%) more likely to report safe disposal of child faeces than caregivers in control villages. Treatment households were 1.9 pp (+79%) more likely to have a stocked handwashing station and 2.9 pp (−16%) less likely to report incidences of child diarrhoea. However, SanNut appears to have had no impact on nutritional practices, such as breastfeeding, vitamin A supplementation or deworming. Non-child outcomes traditionally associated with CLTS, including latrine use and homestead sanitary conditions, were similar in treatment and control groups.ConclusionChild-focused messaging can potentially be integrated into CLTS programming, though this integration was more successful for topics closer to CLTS objectives (sanitation practices, including limiting faecal contamination and handwashing) than for more disparate topics (nutritional practices).Trial registrationPan-African Clinical Trials Registry (PACTR201803003159346) and American Economic Association registry for randomised controlled trials (AEARCTR-0002019).
BackgroundEthiopia launched community-based health insurance scheme in 2011 as part of the revised health care financing strategy to ensure universal health coverage and implementation has started in most part of the country since the launching of the scheme. However, the roll out of the scheme started in Somali Region in 2020—much later the rest of the country. The aim of this study was to assess determinants of enrollment of community-based health insurance among households in Awbarre Woreda, Somali Region, EthiopiaMethodsCommunity based unmatched case control study using a mixed approach of quantitative and qualitative methods was conducted between March and April 2021 and the study participants were selected using multi-stage sampling technique. The quantitative method used interviewer administered structured questionnaire among 216 participants (54 enrolled and 162 non-enrolled), while the qualitative method used key informant interview and focus group discussions in two rural and two urban kebeles of the woreda. The quantitative data was analyzed using SPSS version 20 and thematic analysis was used for the qualitative data. Multivariable logistic regression was used to determine the determinants of enrollment for the community-based health insurance and statistical significance was set at p value of <5%. Result Awareness about CBHI scheme AOR = 9.41(1.16,76.19), households income AOR = 2.73(0.77, 9.57); and being a member of community-based solidarity groups AOR = 2.88(1.17, 7.12) were the determinants for CBHI enrollment and reaffirmed by the qualitative findings. ConclusionsThe enrollment for community-based insurance was determined by being well informed about the scheme, household income, and being a member of solidarity groups at community level. Given the early stage of implementation, enhancing sensitization of the community about the scheme using various community platforms, promotion of the existing community based solidarity groups/associations, diligent targeting of the poor households/indigents and ensuring linkage with any existing social protection program would help to increase enrolment for the scheme.
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