BackgroundThe incidence of cervical cancer in Kenya is among the highest in the world. Few Kenyan women are able to access screening, thus fueling the high cervical cancer burden. Self-collected human papilloma Virus (HPV) tests, administered during community-health campaigns in rural areas may be a way to expand access to screening.MethodsIn December 2015, we carried out a four-day community health campaign (CHC) to educate participants about cervical cancer prevention and offer self-administered HPV screening. Community enumeration, outreach and mobilization preceded the CHC. Samples were sent to Migori County Hospital for HPV DNA testing using careHPV Test Kits. Women were notified of results through their choice of short message service (SMS), phone call, home visit or clinic visit. HPV positive women were referred for cryotherapy following a screen-and-treat strategy.ResultsDoor-to-door enumeration identified approximately 870 eligible women in Ngodhe Community in Migori County. Among the 267 women attending the campaign, 255 women enrolled and collected samples: 243 tests were successfully resulted and 12 were indeterminate. Of the 243 resulted tests, 47 (19%) were positive for HPV, with young age being the only significant predictor of positivity. In multivariate analysis, each additional year of age conferred about a 4% decrease in the odds of testing positive (95% CI 0.1 to 7%, p = 0.046). Just over three-quarters of all women (195/255), were notified of their results. Those who were unable to be reached were more likely to prefer receiving results from clinic (54/60, 90%) and were less likely to have mobile phones (24/60, 73%). Although 76% of HPV positive women were notified of their results, just half (51%) of those testing positive presented for treatment. HPV positive women who successfully accessed the treatment facility did not differ from their non-presenting counterparts by demographics, health history, desired route of notification or access to a mobile phone.ConclusionNearly a third of eligible women in Ngodhe Community attended the CHC and were screened for cervical cancer. Nearly all women who attended the CHC underwent cervical cancer screening by self-collected HPV tests. Three-quarters of all participants received results, but just half of HPV positive participants presented for treatment in a timely fashion, suggesting that linkage to treatment remains a major challenge.Trial registrationNCT02124252, Registered 25 April 2014.
BackgroundCervical cancer is the most frequent neoplasm among Kenyan women, with 4800 diagnoses and 2400 deaths per year. One reason is an extremely low rate of screening through pap smears, at 13.8% in 2014. Knowing the costs of screening will help planners and policymakers design, implement, and scale programs.MethodsWe conducted HPV-based cervical cancer screening via self-collection in 12 communities in rural Migori County, Kenya. Six communities were randomized to community health campaigns (CHCs), and six to screening at government clinics. All HPV-positive women were referred for cryotherapy at Migori County Hospital. We prospectively estimated direct costs from the health system perspective, using micro-costing methods. Cost data were extracted from expenditure records, staff interviews, and time and motion logs. Total costs per woman screening included three activities: outreach, HPV-based screening, and notification. Types of inputs include personnel, recurrent goods, capital goods, and services. We costed potential changes to implementation for scaling.ResultsFrom January to September 2016, 2899 women were screened in CHCs and 2042 in clinics. Each CHC lasted for 30 working days, 10 days each for outreach, screening, and notification. The mean cost per woman screened was $25.00 for CHCs [median: $25.09; Range: $22.06-30.21] and $29.56 for clinics [$28.90; $25.27-37.08]. Clinics had higher costs than CHCs for personnel ($14.27 vs. $11.26) and capital ($5.55 vs. $2.80). Screening costs were higher for clinics at $21.84, compared to $17.48 for CHCs. In contrast, CHCs had higher outreach costs ($3.34 vs. $0.17). After modeling a reduction in staffing, clinic per-screening costs ($25.69) were approximately equivalent to CHCs.ConclusionsHPV-based cervical cancer screening through community health campaigns achieved lower costs per woman screened, compared to screening at clinics. Periodic high-volume CHCs appear to be a viable low-cost strategy for implementing cervical cancer screening.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3195-6) contains supplementary material, which is available to authorized users.
Background Viral load (VL) testing in people living with HIV (PLHIV) helps to monitor antiretroviral therapy (ART). VL is still largely tested using central laboratory‐based platforms, which have long test turnaround times and involve sophisticated equipment. VL tests with point‐of‐care (POC) platforms capable of being used near the patient are potentially easy to use, give quick results, are cost‐effective, and could replace central or reference VL testing platforms. Objectives To estimate the diagnostic accuracy of POC tests to detect high viral load levels in PLHIV attending healthcare facilities. Search methods We searched eight electronic databases using standard, extensive Cochrane search methods, and did not use any language, document type, or publication status limitations. We also searched the reference lists of included studies and relevant systematic reviews, and consulted an expert in the field from the World Health Organization (WHO) HIV Department for potentially relevant studies. The latest search was 23 November 2020. Selection criteria We included any primary study that compared the results of a VL test with a POC platform to that of a central laboratory‐based reference test to detect high viral load in PLHIV on HIV/AIDS care or follow‐up. We included all forms of POC tests for VL as defined by study authors, regardless of the healthcare facility in which the test was conducted. We excluded diagnostic case‐control studies with healthy controls and studies that did not provide sufficient data to create the 2 × 2 tables to calculate sensitivity and specificity. We did not limit our study inclusion to age, gender, or geographical setting. Data collection and analysis Two review authors independently screened the titles, abstracts, and full texts of the search results to identify eligible articles. They also independently extracted data using a standardized data extraction form and conducted risk of bias assessment using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS‐2) tool. Using participants as the unit of analysis, we fitted simplified univariable models for sensitivity and specificity separately, employing a random‐effects model to estimate the summary sensitivity and specificity at the current and commonly reported World Health Organization (WHO) threshold (≥ 1000 copies/mL). The bivariate models did not converge to give a model estimate. Main results We identified 18 studies (24 evaluations, 10,034 participants) defining high viral loads at main thresholds ≥ 1000 copies/mL (n = 20), ≥ 5000 copies/mL (n = 1), and ≥ 40 copies/mL (n = 3). All evaluations were done on samples from PLHIV retrieved from routine HIV/AIDS care centres or health facilities. For clinical applicability, we included 14 studies (20 evaluations, 8659 participants) assessing high viral load at the clinical threshold of ≥ 1000 copies...
Background: Improving patient flow and reducing over-crowding can improve quality, promptness of care, and patient satisfaction. Given low utilization of preventive care in low-resource countries, improved patient flows are especially important in these settings. Objective: Compare patient flow and provider efficiency between two cervical cancer screening strategies via self-collected human papillomavirus (HPV). Methods: We collected time and motion data for patients screened for cervical cancer in 12 communities in rural Migori County, Kenya as part of a larger cluster randomized trial. Six communities were randomized to screening in community health campaigns (CHCs) and six to screening at government clinics. We quantified patient flow: duration spent on each active stage of screening and wait times, and the number of patients arriving at CHCs and clinics each hour of the day. In addition, for four CHCs, we collected time and motion data for providers, and measured provider efficiency as a ratio of active (service delivery) time to total time spent at the clinic. Results: Total duration of screening visits, at CHCs and clinics was 42 and 87 minutes, respectively (p < 0.001 for difference). Total active time lasted longer at CHCs, with a mean of 28 minutes per patient versus 15 minutes at clinics, largely due to differences in duration for group education (p < 0.001). Wait time for registration at clinics was 36 minutes, explaining most of the difference between settings, but sometimes incorporated other health services. Conclusions: There is a substantial difference in patient flow at clinics compared to CHCs. Shorter duration at CHCs suggests that the model is favorable for patients in limiting time spent on screening. Future cervical cancer screening programs designed for scale-up should consider how this advantage may enhance satisfaction and uptake. For clinic-based screening programs, efforts could be made towards reducing registration wait times.
Background Primary healthcare (PHC) systems attain improved health outcomes and fairness and are affordable. However, the proportion of PHC spending to Total Current Health Expenditure in Kenya reduced from 63.4% in 2016/17 to 53.9% in 2020/21 while external funding reduced from 28.3% (Ksh 69.4 billion) to 23.9% (Ksh 68.2 billion) over the same period. This reduction in PHC spending negatively affects PHC performance and the overall health system goals. Methods We conducted a cost-benefit analysis and computed costs against the economic benefits of a PHC scale-up. Activity-Based Costing (ABC) on the provider perspective was employed to estimate the incremental costs. The OneHealth Tool was used to estimate the health impact of operationalizing PHC over five years. Finally, we quantified Return on Investment (ROI) by estimating monetized DALYs based on a constant value per statistical life year (VSLY) derived from a VSL estimate. Results The total projected cost of PHC interventions in the Kenya was Ksh 1.65 trillion (USD 15,581.91 billion). Human resource was the main cost driver accounting for 75% of the total cost. PHC investments avert 64,430,316 Disability Adjusted Life-Years (DALYs) and generate cost savings of Ksh. 21.5 trillion (USD 204.4 Billion) over five years. Shifting services from high-level facilities to PHC facilities generates Ksh 198.2 billion (USD 1.9 billion) and yields a benefit-cost ratio of 16:1 in 5 years. Thus, every $1 invested in PHC interventions saves up to $16 in spending on conditions like stunting, NCDs, anaemia, TB, Malaria, and maternal and child health morbidity. Conclusions Evidence of the economic benefits of continued prioritization of funding for PHC can strengthen the advocacy argument for increased domestic and external financing of PHC in Kenya. A well-resourced and functional PHC system translates to substantial health benefits with positive economic benefits. Therefore, governments and stakeholders should increase investments in PHC to accelerate economic growth.
Objective: To characterize the efficiency of screening through high-volume community health campaigns (CHCs) by comparing the costs and population reach and identify factors associated with gains in efficiency. Access to effective cervical cancer screening remains limited in low-resource settings, especially in rural areas. Periodic CHCs are a novel method of offering screening for HPV at lower costs and higher population coverage than health facilities. Methods:A micro-costing study was conducted within a cervical cancer screening trial to measure efficiency (cost per woman screened) and population uptake of HPVbased screening offered through CHCs in Migori County, Kenya between January and September 2016. Regression analysis assessed relationships between population size and efficiency. Structured observations and qualitative interviews identified implementation factors that affected efficiency in individual campaigns.Results: Communities screening through CHCs had costs per woman screened ranging from US $22.06 to $30.21. Efficiency was directly correlated to overall numbers of women screened, but not to proportion of population screened. Modifiable factors that acted as context-specific facilitators and barriers with a potential impact on efficiency were identified. Conclusion:There was substantial variation in efficiency among CHCs. Cultural factors, health beliefs, and poor coordination among implementation partners as potential key barriers to screening uptake were identified. K E Y W O R D S
BackgroundThe Coronavirus disease 2019 (COVID-19) resulted in the disruption of Sexual and Reproductive Health Rights (SRHR) services in the Eastern and Southern Africa region. To date, studies estimating the impact of COVID-19 disruptions have mainly focused on SRHR services without estimating the economic implication.MethodWe used national service coverage data on the effectiveness of interventions from the lives saved tool (LiST), a mathematical modeling tool that estimates the effects of service coverage change in mortality. We computed years lost due to COVID-19 disruption on SRHR using life expectancy at birth, number of years of life lost due to child mortality, and life expectancy at average maternal death. We calculated the economic value of the lives saved, using the values of statistical life year for each of the countries, comparing 2019 (pre-COVID-19) to 2020 (COVID-19 era).FindingsThe total life-years lost were 1,335,663, with 1,056,174 life-years lost attributed to child mortality and 279,249 linked to maternal mortalities, with high case-fatality rates in the Democratic Republic of Congo, Burundi, and Tanzania. The findings show COVID-19 disruptions on SRHR services between 2019 and 2020 resulted in US$ 3.6 billion losses, with the highest losses in Angola (USD 777 million), South Africa (USD 539 million), and Democratic Republic of Congo (USD 361 million).ConclusionThe monetized value of disability adjusted life years can be used as evidence for advocacy, increased investment, and appropriate mitigation strategies. Countries should strengthen their health systems functionality, incorporating and transforming lessons learned from shock events.
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