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Health Section
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Health Section
Health – Since the declaration of Alma Ata in 1980,
primary health care has been a focus and entry point for broader social
development programmes. Evaluation of primary health care (PHC) implementation
has covered socio-anthropological issues (Ramussen), effects of user fees (Hongoro),
quality of services (Bryce) and impact of PHC (Eng, Afari) There has been tension between vertical programmes such as
immunization and community based intersectoral programmes which has been
partially resolved. National immunization programmes are typically evaluated
annually using mixed methodologies (Frere, Cutts). Immunization coverage has
increased dramatically over the last decade.
Diseases such as polio are now being scheduled for eradication (Hyde). HIV/AIDS is the greatest challenge facing Africa in the
post-colonial era. It is estimated that in mid-1999, approximately 12 million
Africans have died of HIV/AIDS since the epidemic began in 1984.
It is a great challenge for evaluation in the areas of management
training (Shambare), the role of mass media (El-Kamel), treatment strategies (Grosskurth)
and counselling (Dubow). Author:
Afari
E.A, Nkrumah F.K., Nakana T., Sakatoku H., Hori H., Binka F. Title:
Impact of primary health care on childhood mortality in rural Ghana: the
Gomoa experience. Source:
Cent Afr J Med., 41(5): 148-53, 1995 Key Words:
Primary health care, programmeevaluation, health care costs, rural
health, Ghana. Reviewer:
POPLINE abstract. Description:
[A classic example of evaluations of development programme
interventions] The impact of a combination of PHC intervention activities
on child survival, growth, morbidity and mortality were assessed in three
selected rural communities (Gomoa Fetteh, Gomoa Onyadze/Otsew Jukwa and Gomoa
Mprumem) in the Central Region of Ghana from 1987 to 1990.
EPI, provision of basic essential drugs and supplies for the treatment of
common childhood diseases, treatment of the sick child, growth monitoring,
health education, provision of antenatal services, family planning, training and
supervision of Community Health Workers, disease surveillance and special
studies were the major PHC strategies used to improve the health of the child
and the pregnant woman in the three communities.
These activities in their totality have had significant impact on
morbidity and mortality in children under five and on maternal mortality over
the study period 1987 to 1990. Although
malaria, acute respiratory infections and diarrhoeal diseases continue to be
major causes of childhood morbidity, deaths due to these diseases have
dramatically declined. Measles and
other vaccine preventable diseases no longer contribute significantly to
childhood morbidity and mortality. Infant
and under five mortality have been reduced from 114.6/1000 and 155.6/1000 live
births to 40.8/1000 and 61.2/1000 live births respectively. The crude birth rates remained almost the same over the five
year period (43 to 489/1000 pop.) but crude death rates have declined (11 to
12.4/1000 pop.). Author:
Boerma, J.T. Title:
Health information for Primary health care Source:
Nairobi: African Medical & Research Foundation (AMREF), vii, 170p,
1991 Key Words:
primary health care, epidemiology, monitoring, evaluation, nutrition,
AMREF. Reviewer:
UNICEF KCO Documentation Centre. Description:
This book describes kinds of data, the ways of collecting,
analyzing and presenting them, and the organization and methods of health
surveys and community needs assessment, including questionnaires and methods of
analysis. The book, although
written for health workers, may also be used by non-health workers in the field
of primary health care. Authors:
Bryce J., Toole M. J., Waldman R. J., Voigt A. Title:
Assessing the quality of facility-based child survival services Source:
Health Policy and Planning, 7(2): 155-163, 1992 Key words:
health, child survival, facility-based assessment, programme evaluation Reviewer:
Kathleen A. Parker, Centers for Disease Control and Prevention, Atlanta,
Georgia, USA Description:
This article describes the use of the facility-based
assessment (FBA) method to monitor and evaluate the quality of child survival
services in 11 countries in sub-Saharan Africa that participated in the Africa
Child Survival Initiative-Combating Childhood Communicable Diseases (ACSI-CCCD)
funded by the U.S. Agency for International Development.
The FBA is a coordinated set of data collection activities
designed to determine the extent to which health workers correctly diagnose and
treat children and mothers are educated to provide appropriate home treatment.
The Authors describe the method and present examples of how it was modified in
the specific country context. Different
sampling procedures are explained. Details
are provided about the five key data collection activities comprising the FBA:
observations of health worker performance; exit interviews with mothers and
other caretakers; interviews with health workers and supervisors; record review
and equipment and supply inventory. The article includes detailed descriptions of FBA
procedures such as selection and training of interviewers, actual data
collection and data coding, analysis and presentation of results.
Use of the results of the 11 FBAs are discussed by the Authors.
Health worker performance deficiencies pointed to the need for further
in-service training in one country while in another country, logistics problems
(that is, a stock of necessary drugs) were identified as the source of poor
service quality. FBA data were also used to assess the difference in the
quality of service delivery in large vs. small health facilities and in urban
vs. rural areas. Findings indicated
also the need to modify an educational intervention, for example. During exit interviews, mothers reported
“knowing” the sugar-salt solution recipe for rehydration; however,
few of them were able to prepare it. Thus,
increased emphasis was placed during in-service training on health workers’
ability to demonstrate specific measures of the recipe.
In Niger State, Nigeria record reviews showed a decrease in the number of
doses administered between the first BCG vaccine and the last measles vaccine. This led the State Ministry of Health to intensify the
training of health workers in patient education.
Repeat FBA surveys can be used for programmeevaluation, as
shown by the Authors in the case of Niger State. Improved supervisory and health
worker performance was shown to be clearly associated with the in-service
training in management skills for district health supervisors.
The Authors conclude by highlighting two major issues: (1) how to
simplify the FBA method and still provide quality data and (2) whether the
method provides adequate data on facility management. Simplifying the FBA might
involve purposive sampling of “high performers”; use of sentinel facilities;
lot quality assurance sampling (LQAS), and integration of observation checklists
into routine supervisory systems. As
for facility management, the Authors state that the FBA approach does not
address overall clinic management, patient flow, community-clinic interactions
and other issues that can affect the quality of services.
They suggest that FBA be used with other methods, some of which remain to
be developed. Author(s):
Carrington G, Procter N Title:
Identifying and responding to the needs of refugees: a global nursing
concern. Source:
Holist Nurs Pract., 9(2) 9-17 1995 Key words:
nursing, refugees, Afghanistan, Sudan, Yugoslavia Reviewer:
MEDLINE abstract Description:
[Of interest to the nurse/humanitarian worker] Worldwide catastrophic events such as civil war have forced
1 in every 130 people in the world to flee her or his home and become a refugee
or displaced person. The article draws upon contemporary refugee experiences
from Afghanistan, the Sudan, and the former Yugoslavia to introduce the role of
nursing during the refugee journey from flight to asylum seeking. It is hoped
that the article will provide nurses with a beginning awareness of the nurse's
role in the care and comfort of refugees and displaced people. Central to this
role is the gathering of humanitarian, sociocultural, and personal information
to enable extensive networking and relationship building with refugees for
ongoing empowerment and increased problem-solving capabilities. Author(s):
Chandramohan D, Cutts F, Chandra R Title:
Effects of a maternity waiting home on adverse maternal outcomes andhe
validity of antenatal risk screening. Key words:
childbirth, maternity, health, Zimbabwe Reviewer:
MEDLINE abstract Description:
Looks at one policy option for safe motherhood programmes
in settings where emergency obstetric services are not readily accessible.
To evaluate the effect of a maternity waiting home (MWH) on adverse
maternal outcomes and the validity of antenatal risk criteria in predicting
dystocia. METHOD: A hospital-based cohort study was conducted at a
district hospital in Zimbabwe. Information on the presence of antenatal risk
factors, stay at an MWH, and mode and outcome of delivery was collected for each
woman delivering at the hospital during 1989-1991. RESULTS: The risk of
obstructed labor was 16 times higher for those not attending an MWH (n = 2915)
than for those who did attend an MWH (n = 1573) (1 vs. 0.06%, P < 0.005).
Among the non-users, 0.3% suffered a ruptured uterus compared with none of the
MWH users. The presence of any one of the antenatal risk criteria used in
Zimbabwe had a sensitivity of 78%, a specificity of 51% and positive predictive
value of 25% for predicting dystocia. It was concluded that MWHs and antenatal risk screening are
policy options for safe motherhood programs in settings where emergency
obstetric services are not easily accessible. Authors:
Cutts F. T., Glik D. C., Gordon A.,
Parker K., Diallo S.,
Haba F., Stone R. Title:
Application of multiple methods to study the immunization programme in an
urban area of Guinea Source:
Bulletin of the World Health Organization, 68 (6): 769-776, 1990 Key words:
immunization, operational research, KAP, Guinea, USAID Reviewer:
Kathleen A. Parker, Centers for Disease Control and Prevention, USA Description:
This article describes four complementary studies to
evaluate the immunization system in Conakry, Guinea that were conducted under
the auspices of the Africa Child Survival Initiative-Combating Childhood
Communicable Diseases Project (ACSI-CCC), funded by the U.S. Agency for
International Development. In
addition to collecting data that could be used to improve the immunization
program, the studies were part of a continuous ACSI-CCCD effort to integrate
epidemiologic and social sciences research methods in its operational research
component. In Guinea, four studies were carried out between October
1988 and April 1989: a health facility survey, key informant interviews at
health centers, focus groups in the community about vaccination services, and a
knowledge, attitudes and practice (KAP) survey. The Authors state that multiple
methods of operational research were needed to assess service characteristics
(accessibility, management, health worker skills, knowledge and attitudes); user
characteristics (social and demographic factors); and the interaction between
the users and service providers. Complementary
data sets were more likely to identify why the immunization programme could not
maintain high levels of vaccination coverage following successful vaccination
campaigns and provide guidance for the development of a comprehensive
immunization strategy. Following a summary of the results of each study, the
Authors present examples of the divergence and convergence of some important
findings. Divergence was found in
relation to vaccination costs. The focus groups indicated a concern among
mothers about high costs, while in the KAP survey, the amount of money spent on
vaccination was related to the number of vaccinations already received.
The discrepancy was possibly explained by recent fee increases; however,
the divergent findings underscored the need for programme planners to be
sensitive to consumers’ attitudes towards affordability.
The results related to the quality of health services were highly
convergent. Missed opportunities
for vaccination were detected during observation of health worker practices in
the health facility survey and estimates from reported health center visits in
the KAP study; providers’ and users’ attitudes toward the services were also
less than optimal. These and other
findings about service delivery clearly indicated needs for improvement. Strengths and weaknesses of each study method are
described. Strengths of a multiple method approach include the ability to
collect important data in a relatively short time, using modest resources.
Analysis of data and its feedback to the programme were accomplished in a
timely fashion. The qualitative methods (key informant interviews, focus group
interviews were very useful to explore ”why” questions and contextual
factors, but there was a sampling bias and the studies had a narrow, limited
scope. The health facility served
as a means of training supervisors to observe health worker practices,
presumably enhancing their supervisory skills.
The quantitative KAP survey evaluated both provider and user factors
(service delivery and socio-structural issues) and their interaction, but was of
limited use for individual factors of knowledge and attitudes, best assessed in
the complementary qualitative studies. Following dissemination of the results, a workshop was held
to discuss the findings and propose solutions.
Two strategies to increase coverage were selected for action: avoid
missed opportunities and conducting home visits to identify and refer
defaulters. A training session for
health workers in Conakry was then organized. The Authors conclude by suggesting that data from several
complementary small-scale studies, such as those one in Conakry, that examine
different programme components, may be more useful and timely than data from
large national surveys. Author:
DeCock K.M., Ekpini, E., Gnaore, E., Kadio A., and Gayle, H.D. Title:
The public health implications of AIDS research in Africa. Source:
JAMA,. Aug 10, 272(6), P. 481-6, 1994 Key words:
AIDS, public health, strategy, Africa Reviewer:
MEDLINE abstract Description:
[Of interest to evaluators who will need to document the
effectiveness of the many interventions to mitigate the effect of HIV/AIDS]. The human immunodeficiency virus/acquired immunodeficiency
syndrome (HIV/AIDS) epidemic has led to greatly increased international
collaboration for medical research, mainly epidemiologic in nature, in Africa.
Greater understanding of HIV/AIDS has resulted, and considerable training and
technology transfer have occurred. However, analytic and descriptive research in
countries heavily affected by AIDS has been slow to turn to assessment of
interventions, and practical benefits to those countries' public health and
policies have lagged behind scientific knowledge. This article considers the
public health implications of selected HIV/AIDS research in sub-Saharan Africa
and discusses opportunities for interventions and more applied research. Topics
covered include HIV testing and its role, surveillance, control of sexually
transmitted diseases, the vulnerability of youth and women, tuberculosis,
HIV/AIDS care, and the inadequacy of resources currently committed to HIV/AIDS
prevention and control in resource-poor countries. Research on HIV/AIDS in
Africa has yielded crucial information but now should prioritize interventions
and their evaluation. Specific goals that might limit the effects of the
HIV/AIDS epidemic in resource-poor countries are achievable given vision,
commitment, and resources. Author:
Dubow, J., and Ouango, J.G. Title:
Study of HIV/AIDS and STD counseling services in Guinea (Note: Available also in French.) Source: USAID
[Unpublished 1994]. Contract No.
HRN-5972-C-00-4001-00, August 28 – September 8, AIDSCAP,.1994 Key Words:
evaluation, HIV/AIDS, counseling, Guinea Reviewer:
POPLINE abstract. Description:
[Authors notes: For many countries in Africa, psychosocial
counseling is gaining importance, as more people are confronted with diminishing
traditional family support mechanisms resulting from the HIV/AIDS emergency.] An evaluation of human immunodeficiency virus
(HIV)/acquired immunodeficiency syndrome (AIDS) counseling services in Guinea,
West Africa, confirmed that the psychological care of HIV-infected persons is
receiving serious, sustained attention. Counseling
teams have been established at the two major hospitals in Conakry, and
counselors and general practitioners collaborate on pre- and post-HIV test
counseling. Counseling activities
are beginning to decentralize to the district level. Counselors obtain informed consent for HIV testing, deliver
test results (positive and negative), discuss prevention, provide psychosocial
support, and assess the patient’s care arrangements. The national AIDS programme has prepared a training manual on
counseling HIV/AIDS patients which stresses the need to integrate counseling
into all aspects of patient care. In
the community, a social network to support counseling activities, comprised of
religious groups, women’s organizations, and traditional healers, is emerging.
Obstacles to effective counseling include inadequate mechanisms for
follow-up of HIV-infected patients, breaches of patient confidentiality, a lack
of adequate supervision for counseling staff, and the reluctance of some
physicians to perform this function. (You
may request the complete document by mail, fax or e-mail.
Please provide the document number. Document Number: PIP 115812). Author(s):
El-Kamel, F. Title:
The role of mass media and interpersonal communication in HIV/AIDS
prevention: Results of a pilot campaign for Egyptian workers and university
graduates. Source: Cairo: Centre
for Communication, Training, Documentation and Production, UNICEF, 1997 Key words:
mass media, focus groups, communication, HIV/AIDS, Egypt Reviewer:
Nimal Hettiarachy, UNICEF Description:
A pilot project on “Youth Protection” was supported by
UNICEF and implemented by the Centre for Communication, Training, Documentation,
and Production of Cairo University between August 1996 and September 1997.
Major objectives were to: 1) gain current and in-depth information on
relevant knowledge, attitudes and behaviors related to HIV/AIDS, and identify
risk factors among youth as a key population group; 2) develop key prevention
messages suitable for youth and similar target groups; 3) disseminate essential
prevention messages among one particular youth group, namely, Cairo University
students, who may further disseminate information gained; and 4) develop a model
for working with university students which can be replicated in other
Universities in Egypt. Implementation began with baseline data collection (through
survey and focus group discussions) to assess Knowledge, Attitudes, and
Practices (KAP) among the university student target population and identify
appropriate intervention techniques and message strategies.
Small groups of university students from 10 different faculties were then
trained in interpersonal communications skills related to HIV/AIDS and on
relevant prevention measures. Ten
student rallies were organized to convey essential messages.
Impact evaluation was conducted through pre/post-rally interviews with
samples of 20 randomly selected students. The main findings of the study point to misconceptions and
lack of essential knowledge among university students on HIV/AIDS, including
means of protection from infection. Focus
group discussions indicate that a significant number of Egyptian youths are
engaging in high-risk behaviors. Effective
communication techniques can have an impact.
Well-organized face-to-face activities such as the youth rallies can be
an effective means of conveying socially sensitive health messages related to
HIV/AIDS. It is recommended that
the methodology be replicated among other youth groups; that more information
materials; including video be developed and that mass media be used in a more
planned, targeted, systematic and sustained manner to increase impact. Linkages
between mass media and interpersonal communications should be identified and
strengthened. Both the process and
the result of the project are useful in the planning and implementation of
HIV/AIDS prevention in Egypt. Author(s):
El Tawila, S., David, P., and Bisharat, L. Title:
Child Well-Being in Egypt: Survey Findings with Implications for Policy Source: UNICEF, Egypt
/ Social Research Center, American Univ. in Cairo, 1988 Key words:
policy, survey, MICS, UNICEF, Egypt Reviewer:
Nimal Hettiarachy, Regional Senior Policy Analyst, UNICEF, MENARO, Amman,
Jordan. Description:
[This report incorporated the framework of the Convention
on the Rights of the Child into a household survey, going beyond standard
reporting to attract attention of policy makers] A Multiple Indicator Cluster Survey (MICS) was conducted in
Egypt in 1996/97. Its threefold
objectives were to 1) assess the status of children and their families and
develop a cost-effective tool for regular assessment of trends; 2) expand
perspectives on children’s well-being beyond the traditional focus on health
through to include child labour, disabilities, educational exclusion, and access
to water & sanitation; and 3) examine disparities between unplanned
settlements and other areas, and provide separate, more detailed estimates for
the six governorates where UNICEF has area-based programmes. The MICS instrument emphasized “invisible” children and
those in need of special protection, including children in families that are
least likely to have access to health services, children never enrolled in
school, and children living in the “illegal” neighborhoods of Egypt’s
burgeoning cities. The National
Council for Childhood and Motherhood, which brings together all parties working
in the best interest of the Egyptian children, helped promote investigation of
these difficult areas and encourage assessments that lead to actions.
The Egypt MICS thus went beyond the standard measurement of progress
towards goals for children, and used the framework of the Convention of the
Rights of the Child as a guide to assess child well-being and attract policy
attention. The crisp policy focus of the MICS and the report of
results came from the involvement of programme managers and specialists in the
planning and interpretation of the survey.
A forum organized by the Social Research Centre of the American
University in Cairo in 1997 drew together a number of specialists in nutrition,
disability, education and health to examine the results of the survey and
discuss policy implications. This
contributed substantially to the Mid-Term Review of UNICEF’s Programme of
Cooperation with the Government of Egypt. Programmatic issues arising from the MICS include: the need
to address spatial disparities, especially in immunization, education and safe
sanitation; promotion of girls’ education, particularly in rural hamlets and
“illegal” urban settlements; a plan of action to address the multiple causes
of undernutrition; attention to the plight of working children including
improved working conditions and safeguarding their right to education; quality
training for physicians in the proper management of the sick child; and
recognition of childhood disabilities as a national issue warranting policy
attention. The survey design
expressly foresaw its use for repeated monitoring of progress, incorporating
statistical parameters that would make this possible.
This makes it valuable vehicle for reassessing progress in these and
other areas. Author:
Eng, E., Glik, D., and Parker, K. Title:
Focus-group methods: effects on village-agency collaboration for child
survival Source:
Health Policy and Planning; 5(1): 67-76, 1990 Keywords:
child survival, health, focus groups, health education, in Côte
d’Ivoire, Guinea, Rwanda, Togo, USAID Reviewer:
Kathleen A. Parker, Centers for Disease Control and Prevention, USA Description: The Authors describe the focus group methodology and its
increased use in the design and evaluation of community health education
programs. In the Africa Child Survival Initiative-Combating Childhood
Communication Disease Project (ACSI-CCCD), funded by the Africa Bureau of the
U.S. Agency for International Development, health education staff were trained
to use focus groups in Cote d’Ivoire, Guinea,
Rwanda and Togo. While
national level staff in Cote d’Ivoire, Guinea, and Rwanda were trained to
plan, conduct and analyse focus group interviews, in Togo, mid-level health
workers were trained to not only implement community health education
activities, but also to design and evaluate them with the communities they
served. The training of the health
workers in Togo and their subsequent use of the focus group methodology had both
anticipated and unanticipated effects. In all, 81 focus groups were completed with 324 women in
the nine villages. As expected, the
use of focus groups brought the health workers into more direct contact with
their communities. It also led to
health education activities that were more responsive to the needs of the
community. The focus group findings
indicated the need for community-based educational activities (through
“mini-campaigns” involving village health committees, school children, male
village leaders) rather than targeted messages to change the knowledge and
motivations of individual mothers. A follow-up survey to evaluate the impact of
community health education on vaccination coverage showed increases that were
statistically significant in all the villages. The Authors discuss the risk of public health researchers
using focus group techniques in public health programme planning and evaluation.
As applied in the field of marketing and advertising, the researcher is
an outsider, someone not having an ongoing relationship with the persons they
are interviewing. However, if a
public health programme requires community participation for acceptance and
sustainability then the interrelationship among providers, consumer and
community members is essential. In
Togo the use of focus groups was an integral part of community-based programme
planning and evaluation. The
focus groups not only generated data. They
also served to stimulate a process of interaction between the moderators/health
workers and community members. Although
“in the community”, health workers learned much more about the realities of
community life; rather than experts with all the answers, health workers became
listeners and learners, with mothers as their teachers.
By encouraging increased participation by mothers and other village
members, community competence was enhanced and collaborative efforts fostered
between communities and health workers. The Authors conclude by indicating that the intervention
and evaluation activities fostered by the use of focus groups in Togo “provide
a welcome lesson in how research methods and practice methods can be mutually
reinforcing and can result in a dialogue between health workers and the
communities they service, rather than in a one-sided research project”. Authors:
Frere, J.J., Kone, I., Durrand, T., and Creits, K. Title:
Evaluation of Madagascar EPI Source:
UNICEF Madagascar, 1989 Key words:
immunization, Madagascar, UNICEF Reviewer:
Chrystian Solofo-Dimby, UNICEF Description:
This is a mid-term evaluation of the National Immunization
Programme (NIP). The Authors analyse the extent to which goals and specific
objectives of the NIP as mentioned in the Plan of Operations, 1987-1991, have
been achieved, focusing on operational and financial aspects. The main task was
to assess to what extent available inputs would contribute to a significant
increase in immunization coverage, which was estimated at 35% in 1989. A general context of the health situation in Madagascar is
presented first, including a review of objectives of the NIP. The Authors
analyse the structure of the Ministry of Health, and focus on the Immunization
Department. The analysis notices the lack of authority of this department vis-à-vis
health centers. Budget and operations planning processes are also analyzed,
focusing on different aspects such as logistics, technical capacities,
monitoring, and finance management. Logistic constraints are reviewed. They are mainly related
to important delays in distribution of equipment and difficulty to ensure a
regular distribution of vaccines from the Immunization Department without
interrupting the cold chain. A major constraint is the limited stocking capacity
at central level, leading to frequent vaccines orders by the Immunization
Department. At peripheral level, most districts are expected to be equipped
during the current year, according to their respective needs in vaccine storage
and transportation. At technical level, the Authors note frequent violation of
rules of sterilization and utilization of vaccines. The immunization schedule is
not yet completely under control and the number of immunization sessions are
insufficient. The Authors stress the need to improve training of health
personnel and to involve midwives. Regarding monitoring aspects, supervision needs to be
reinforced and to be more systematic. Quality of the current information system
does not allow a regular performance evaluation of activities as well as
monitoring at sub-national levels. Therefore, improvement of the monitoring
system requires a mobilization of health personnel at all levels and more
motivation from them. The Authors present a detailed study of financial aspects.
They address the issue of financial self-sufficiency and the lack of a direct
relationship between increase of available resources for EPI and increase in
immunization coverage. Conclusions and recommendations from the Authors are mainly
about operations, cold chain and management of finances. One essential
conclusion is that, based on current equipment status, a noticeable increase of
immunization performances would have to take place in the following months, so
as to double the immunization coverage by end 1989. Author:
Ginsberg, P.E. Title:
Decentralization of Mental Health Care in Sub-Saharan Africa: Kenya. Source:
Unpublished technical report. Utica
College of Syracuse University, 1600 Burrstone Road, Utica, NY 13502, USA.
31 pages plus appendices, 1990 Keywords:
mental health, Kenya Reviewer:
Author Description: [The topic of mental health is rarely covered in the
African literature. This article discusses two different models of
decentralisation and the tension between them.] Using a multimethod approach, this report describes the
history and status of Kenya's mental health system as of 1990.
Published materials, World Health Organization reports, training
materials, and documents relative to passage of Kenya's Mental Health Act of
November, 1989 serve as background to questionnaires, site visits, and
interviews with the Director of Mental Health, three members of the University
of Nairobi Department of Psychiatry, the director of Nairobi's Mathare Hospital,
and administrators of 13 decentralized service sites.
Because cooperation from mental health facilities was extraordinary, with
information obtained directly from 77.3% (34 out of 44) of those public
facilities that were known to be operating, and because site administrators were
given the opportunity to comment on draft materials, the picture of Kenya's
mental health system as of January, 1990, may be presumed to be quite accurate. In addition to the history of western mental health care
provision in Kenya, topics discussed in the report include reported age and
gender of service recipients and prevalence of diagnostic groups in treatment;
inpatient capacity and staffing patterns; outpatient, day treatment,
rehabilitation, evaluation and referral services; consultation, home visitation,
and public education functions; material resource needs, and five year
projections for change as perceived by service administrators. Budget figures,
which were available, are not included. The concluding discussion and recommendations examine the
tension between two models of decentralization, the expert model and the primary
health care model. Attention is
given to personnel needs, general fiscal issues, and information needs related
to planning and monitoring. Authors:
Glik, D.C., Parker, K., Muligande, G., and Hategikamana, B. Title:
Integrating qualitative and quantitative survey techniques Source: Intl Quarterly
of Community Health Education, Vol. 7 (3): 181-200, 1986-1987 Key words:
malaria, diarrhea, KAP, methodology, Rwanda Reviewer:
Kathleen A. Parker, Centers for Disease Control and Prevention, Atlanta,
Georgia, USA Description:
This article describes an application and field testing of
the methodological technique of triangulation which involves the collection of
both quantitative and qualitative data to assess the same or similar sets of
issues. Triangulation was
used in Rwanda as part of baseline and formative research to evaluate maternal
behaviors related to two child survival interventions: malaria control through
presumptive treatment of fever with chloroquine and diarrhea control using oral
rehydration therapy. The
triangulation approach was designed to enhance the analysis,
interpretation and use of the data.
A two-part national population-based survey to assess the knowledge,
attitudes and practices (KAP) of Rwandese mothers was conducted.
The Authors describe a component of this national survey
that used a triangulation approach to (1) validate findings and expand areas of
inquiry (through a quantitative sub-sample survey of respondents from the
national survey) and (2) examine contextual factors related to the quantitative
findings (through qualitative in-depth individual and focus group interviews). Thirty-three questions were the same on the national and
sub-sample quantitative surveys. For
85% of the questionnaires in the sub-sample, the range of different responses
for the 33 questions was 0 to 5. Estimates
of duration, quantity and distance proved the least reliable between the two
surveys. The national survey was
thus reliable for the most part. Triangulation of the data revealed both similarities
(convergence) and dissimilarities (divergence) between the quantitative and
qualitative data sets. While there was convergence between national and
sub-sample data related to service utilization (about 40%), further analysis of
the sub-sample data revealed different utilization patterns for older mothers
(less use of clinic) and female children (more likely to be treated with home
remedies). An interesting example
of divergence was the low percentage of mothers who took their children with
fever to a clinic found in the quantitative survey (42%) in contrast to the
practice clearly reported across all focus groups that claimed febrile children
were indeed taken to a clinic. The
same applied for the use of oral rehydration solution. The Authors acknowledge that such divergence may reflect
self-report bias. Identifying convergence or divergence in the findings is
important in order to determine the reliability of the data and to provide
insights into the factors affecting the values, perceptions and behaviors of the
Rwandese mothers. Quantitative
surveys, while perhaps able to accurately estimate behaviors, do not suffice for
helping us to understand the “whys” of the behaviors.
Qualitative methods explore the “whys” and help us to better
understand the numbers. When
quantitative and qualitative methods are used together, they allow the research
to be shaped by a closeness to the problem and the constant comparison back and
forth between methods. The Authors conclude by stating that “such an integrated
methodology can maximize the amount of usable data collected in the field for
the amount of time spent and overall costs expended.” They recommend the use
of complementary methodologies for planning and evaluating programs in
developing countries. Author: Government of
Kenya (GOK). Title:
Review and Evaluation of National Action to Give Effect to the Aim and
Principles of International Code of Marketing Breast-Milk Substitutes. Source: Nairobi:
UNICEF KCO / Ministry of Health, 34 p. + annexes, 1991 Key words:
Infant-feeding breastfeeding policy Reviewer:
UNICEF Kenya Country Office Documentation Centre. Description:
[Of interest to policy makers and advisors on
breastfeeding] Recognizing the importance of breastfeeding, WHO, UNICEF
and 118 countries ratified the International Code of Marketing of Breastmilk
Substitutes. Kenya, as a member
country, adopted and gazetted the Kenya Code for Marketing of Breastmilk
Substitutes which has been in effect since 1983. This document highlights the findings of the review and
evaluation of the Kenya Code. Author(s):
Gray, C.S. Title:
A case history based assessment of female genital mutilation in Sudan Source:
Evaluation and Programming Planning, 21 (4), 429 - 436, 1998 Key words:
FGM, life histories, Sudan, CEDAW Reviewer:
Jacqueline Aligula, UNICEF, Kenya Description:
The author's objective is to show how presentation of
various aspects of a subject can lead naturally to conclusions suggesting ways
to deal with problems and to instigate change.
She uses the subject of female genital mutilation to demonstrate how,
through discussion, solutions are suggested in order to improve the lives of
Sudanese women. In this article the author has discussed the subject of
female genital mutilation through a selection of 15 excerpts from a narrative
derived from interviews with well-educated students or professional prominent
Sudanese women. The breadth, depth
and context of interviews (narratives "in their own terms about what had
been significant in their lives") provide better insights for evaluation
and planning strategies than pre-conceived questionnaires and rigid statistical
methods. The original interview form ensures an "inside", contextual
presentation of the subject, providing clues for approaches towards elimination
of the practice. With evaluation and planning strategies in mind, the issues
are placed in the conceptual framework of the segregation of the sexes and
viewed through the ideas of gender-based discrimination as outlined in CEDAW.
The author provides background information on the segregation of sexes, with
practical examples from the narrative interviews, giving an insight on, not only
beliefs in female genital mutilation, but also male belief in controlling female
sexuality, i.e., inferior status of women compared to male in Sudan.
The author approaches this issue in relation to other pressing health
issues. In conclusion, the author cites that an evaluation of
issues surrounding the phenomenon of female genital mutilation has to
incorporate all aspects expressed in the interviews (as well as aspects not
necessarily dealt with) and can be complemented through information obtained
using other methods. The
author adds that in order for changes to occur, many aspects have to be looked
into, for instance the involvement of the family, religion, traditions,
education and empowerment of women from an early age. Author(s):
Grosskurth, Heiner, Mosha Frank, Todd, James et. al. Title: Impact
of improved treatment of sexually transmitted diseases on HIV infection in rural
Tanzania: randomised controlled trial. Source: Lancet,
346:530-36, 1995 Key words:
HIV, community trial, behavior change, Tanzania Description:
This evaluation was the first randomised trial to
demonstrate an impact of a preventive intervention on HIV incidence in a general
population. This article is a
‘must-read’ for evaluators interested in application of the rigors of
scientific research to programme impact. This
review focuses on the different methods used. The researchers evaluated the impact of an STD intervention
programme that had five components. These
were: a clinic and laboratory for referral of STDs; training of existing staff
from health centers and dispensaries in the intervention areas; a supplementary
drug delivery system to complement the existing system; regular supervisory
visits to each health facility for in-service training and monitoring; and
finally, periodic visits by health educators to provide motivation to
communities for prompt treatment of STDs. In the impact evaluation, 12 communities were matched and
paired in the catchment of a rural health Centre and its satellite dispensaries.
Communities were selected and matched to reflect known variations of HIV
prevalence among various populations (higher along roadside and railway
settlements than rural villages). The
matching criteria were roadside, lakeshore, island, rural location, geographical
area and prior STD attendance rates at the health centers.
The impact of the intervention programme on HIV incidence was measured in
a random cohort of 1000 adults from each selected community.
Clusters of households were sampled randomly from the population residing
within 90 minutes walking distance from the health Centre.
All adults aged 15-54 year olds were eligible for inclusion, and baseline
data was obtained from virtually all who were enrolled. Biological evidence was used to support the findings.
Incidence of HIV was measured over the two-year period, and evidence of
STDs was diagnosed by qualified clinicians and confirmed through laboratory
findings. Furthermore, to determine whether any differences in HIV
incidence between intervention and comparison groups may have resulted from
differences in sexual behavior, separate random sampling of one in eight cohort
members was done after the baseline and follow-up surveys. Selected individuals
were assessed on sexual attitudes and practices in a detailed questionnaire. In their statistical analysis, the researchers measured the
risk ratio (RR) of HIV incidence in the intervention community relative to the
comparison community. They obtained
geometric means of the pair-specific RRs, testing statistical significance with
the paired t test on the logarithms of the RRs. They adjusted for observed differences at the baseline
between the matched pairs on items such as age group, sex, travel out of the
village, (ever) reported history of STD, and male circumcision. The number of communities and the size of the cohort were
chosen to provide 80% power of detecting a 50% reduction in annual incidence
from 1% to 0.5%, taking account of the expected level of between-community
variation in incidence rates. Their
findings led them to conclude that improved STD treatment reduced HIV incidence
by about 40% in the study population. (RR=0.58, 95%CI 0.42-0.79, p=0.007). Author(s):
Hongoro, C., and Chandiwana S.K. Title: The
effects of user fees on health care delivery in Zimbabwe. Source: Harare:
Planning and Management Department, Ministry of Health and Child Welfare/
UNICEF, 1994 Key words:
health, user fees, service utilization, outcome evaluation, Zimbabwe Description: This is a report of a study carried out to find out if the
application of user fees collection was having any unwanted effects. The Authors reviewed existing data, supplemented by
collection of primary data at health facility and community level.
They compared their findings to the years 1990 and 1991 to find out any
differences before and after the strengthening of user fees collection.
The study also provides examples of the effect of increased user fees for
health from other countries (Ghana, Lesotho and Kenya) and reports on the
proportion of budget allocation to health care from 1988/89 to 1992/93. Zimbabwe
experienced a decline of 29% in real terms from 1991 to 1992. Real recurrent expenditure per capita on health dropped by
25% from Z$18.17 in 1990 to Z$13.71 in 1992. They were limited in their analysis of gender and age by
data collection forms at the Ministry of Health and Child Welfare, which did not
have gender categories or age categories except in broad bands of under-five and
over-five. They found that after the enforcement of user fees
collection, outpatient attendance dropped while inpatient attendance increased.
However, the average length of stay for in-patients dropped from nine to
seven days. Antenatal clinic
attendance fell in 1991, but maternity admissions increased, coupled with an
increase in unbooked deliveries and babies born before arrival.
The cost recovery ratio (the ratio of revenue collected
divided by recurrent expenditure) averaged 2% per year from 1984/85 up to
1990/1991, and went up slightly to about 4% in 1991/92 after the enforcement of
user fees collection. Waiting time
was increased at facilities to enable screening of patients for ability to pay.
The increased bureaucracy in screening was not facilitated because of a
lack of information on requirements or process for determining eligibility.
In the KAP portion of the study, nearly 45 per cent felt that some type
of health insurance coverage would be an alternative to the user fees scheme. Recommendations focused on the need for government to
improve processes of screening, health service delivery (reduce waiting times),
and reassess the cost of this exercise on the insignificant financial returns. Author:
Hyde, K.A.L. Title:
Malawi Against Polio (MAP) programme evaluation. Source:
Centre for Social Research, University of Malawi, Zomba, 1992 Key words:
polio, Malawi Reviewer:
Patricia Hari, Kenya Description:
Malawi Against Polio (MAP) is a clinic-based voluntary
organization that carries out medical rehabilitation of victims of polio and
other disabling conditions through provision of medical assistance, appliances
and other support. MAP relies on
government, local voluntary contributions and external donor support to run its
activities. It works with various agencies that provide services and resources
for the disabled in Malawi. Ten years after it started functioning, an evaluation to
(a) assess the present aims and activities in relation to its original aims, (b)
evaluate the current organizational structure and compare it other similar
organizations, (c) assess the present position of MAP in the delivery of
services to the physically handicapped, (d) assess whether MAP should expand
into or contract from any of its ongoing components, and (e) assess the
proportion of the current budget that is spent on service provision was carried
out. The author relied mainly on the use of desk reviews of MAP
and government policy documents as well as interviews with MAP clients and
representatives of various other organizations offering services to disabled
persons in Malawi. Data from the MAP 1991 database and interviews carried by
the author with representative samples of clients in various clinics revealed
that the majority of MAP clients were male and aged below 20 years.
The rate of their participation in education was reported to compare
favorably with those of the general population.
However, as a group, they were at a disadvantage for social
participation. For example, very few reported having received any form of
vocational training. Of those interviewed about a quarter reported earning
income from sources that include salaries, pensions, farming and small
businesses. Patients reported
having heard about MAP from a variety of sources including radio and social
welfare officers. One of the identified problems was the limited access of
the disabled to rehabilitative services. Suggestions
for strategies to address this problem included increasing awareness of the
availability of the services, expanding the number of clinics especially in
remote areas and exploring the efficacy of the community based rehabilitation
strategy. Needs assessment should
be an integral part of this expansion. This
expansion would also have implications in terms of production of aids and
appliances. MAP should therefore
explore and develop strategies for cost effectiveness and financial
sustainability. Collaboration
between MAP and other organizations working with disabled persons would improve
effectiveness and efficiency in the current use of resources and provision of
services. It was noted that the majority of disabilities resulted
from a wide variety of preventable causes.
This highlighted the need for MAP to involve itself in community
education to control and prevent these types of disabilities and the need for
MAP to change its name, as it no longer dealt with clients with disabilities
exclusively resulting from polio. MAP
should take special measures to ensure equitable access to services for those
marginalized groups within the disabled population, for example, the deaf,
children with learning difficulties and epileptics.
It was also urged that disabled people be encouraged to participate more
actively and take more responsibility in the process of their own rehabilitation
to discourage dependency and foster self-reliance. Authors:
Ramussen, C., Ramamonjisoa, E., and Gonzales, G. Title:
Socio-anthropological study on the use of health care and services in the
city of Antananarivo Source:
UNICEF Madagascar, 1998 Key words:
health service, quality, cost, utilization, traditional medicine,
Madagascar, UNICEF Reviewer:
Chrystian Solofo-Dimby, UNICEF Description:
This study is part of a baseline research for a programme
of revitalization of Basic Health Centers in the city of Antananarivo, based on
the strategy of the Bamako Initiative. It aims at a deeper understanding of the
rationales and aspirations of citizens and users of health services. The study
makes also an attempt to identify strategic orientations for an improvement of
quality health care, as well as of organization of the management of the health
care system. In particular, the problem of socio-economically-vulnerable groups
is addressed through an analysis of reasons for non-utilization of public health
services that are expected to provide quality health care at affordable cost. The Authors adopted a qualitative approach to explore two
themes to address these issues, (i) utilization of health care services, and
(ii) key points related to revitalization, such as perceptions on quality of
existing services, perceived needs for its improvement and community
participation in the management of the health care system. They made allowances
for rural-urban differences. Data are collected through semi-structured
interviews. The study reveals self-medication as the first reflex of
citizens in the face of disease, in spite of the availability of several health
care alternatives. Self-medication consists generally of mixing modern and
traditional medicine. The Authors find that reasons for the non-utilization of
the existing services are multidimensional. Beyond cost of health care, which
constitutes a main constraint to obtaining efficient services, findings show
behavioral factors such as fatalism, complex towards health personnel and lack
of confidence in the efficacy of health care play a role. Time to consult health
personnel is also mentioned as a constraint. The Authors characterize fatalist attitudes by a common
perception of minor diseases considered as “usual” on the basis of their
frequency. For this type of disease citizens do not feel any need for medical
consultation, its gravity being assessed in terms of duration and status of the
sick person, rather than in terms of type of disease. According to the Authors, the lack of confidence in the
effectiveness of health care is linked to a strongly negative opinion of
citizens on public health services. Common
concerns are mainly about limited capacities of health personnel in terms of
seriousness and attention, welcoming and technical capacity, and about
efficiency of health system in terms of availability of drugs and medical
equipment, community participation in the management of health services. Time to
consult health personnel is also mentioned as a constraint. Author:
Prendiville, N. Title:
The role and effectiveness of traditional birth attendants in Somalia Source:
Evaluation and ProgrammePlanning, (21)
4: 353-361, 1998 Key words:
TBA, maternal mortality, maternal morbidity, Somalia Reviewer:
Jane Mwangi, UNICEF Description:
The aims and objectives of carrying out this evaluation
were to define the current role of the TBAs in Somalia, review and evaluate the
training of TBAs in recent years and evaluate the effectiveness of
TBAs in supporting safe motherhood initiative in Somalia and to make
recommendations on future support to TBAs.
Choice of methodology was based on a desire to collect
qualitative data in a country where security is a problem.
Data collection was carried out in areas, which were accessible and
considered secure during the evaluation period.
Semi-structured interviews using pre-tested questionnaires, discussion
and observation helped the interviewees feel at ease especially in discussing
things, which they felt, were personal in nature.
The findings of the evaluation indicate that the status of women in
Somalia is low and their health is not a priority.
Current high maternal mortality rate are not recognized as a serious
problem since “only one or two women die for every hundred of births”(!).
Training of TBAs has been done, as there are few qualified
personnel to assist in deliveries and also due to lack of functional health
facilities. TBAs do not play a strong role in antenatal period, and visits to
pregnant women usually occur informally if the TBA is a neighbour or friend.
In cases where a TBA is linked to an antenatal clinic run by a qualified
midwife, she is in a position to encourage women to attend the clinic for full
assessment. Many TBAs attempt to
handle difficult deliveries and thus a trained TBA who encourages referral may
be seen as less skilled than the others. Two incidences are cited which bring
out the general lack of confidence in referral hospitals.
There is a general fear of the expenses involved and families generally
associate hospitals with bad outcomes, resulting in refusal to and delays in
referring women to them. Lack of
prompt attention by health professionals towards referred women with serious
complication also discourages families in taking women to them.
In general, TBAs have little influence in the management of
life-threatening emergencies. In conclusion, the author brings out the fact that while
trained TBAs may have some impact on maternal morbidity through improved
delivery practices, TBA training in isolation cannot be used as a single
approach to improving maternal and child mortality levels.
The author goes on to say that any programme that aims to address
maternal mortality in Somalia has to recognize that TBA cannot function well
without a supportive and informed community and a functional referral system.
The community therefore needs to be informed of a need to prioritize the
health and recognize the special needs of pregnant women and importance of early
referrals in case of complications. Author:
Shambare, R.M. Title:
Evaluation of the management training programme for members of Zimbabwe
AIDS Network (1993-1995). Source: Zimbabwe AIDS
Network, Harare. USAID/UNICEF, 1997 Key words:
management, training evaluation, Zimbabwe, USAID, UNICEF Description:
Following a call by non-governmental organizations (NGOs)
to improve their ability to run and manage AIDS programmes, UNICEF and USAID
assisted the Zimbabwe AIDS Network to train representatives of member
organizations in project and practical management. This study documents the impact of the training carried out
between 1993 and 1995, on the organizations and the individuals involved.
It also examines ways to improve such activities in the future, both in
terms of content and organizational logistics. This paper could also fit in the
capacity building section. Key questions addressed were whether the training had
impacted on organizational development, whether the training had been
appropriate and how selection and follow-up could have been strengthened to
improve the impact of training. The
study sought to find out what major management and programming issues were
encountered by NGOs involved in HIV/AIDS issues that could be addressed through
skills training. A total of about 155 senior management personnel were
trained. For the evaluation,
interviews were carried out with key informant representatives of 25
organizations, trained programme personnel (excluding directors) and colleagues
of trainees. The needs and roles of
six major stakeholders as well as the extent to which they effectively played
their roles and how they affected the overall effectiveness of the training were
examined in turn. The training resulted in improved time management and
delegation, but not in financial reporting, suggestive of a weak programme
design and justification capacity of trainee organizations. Participants improved on an individual basis, but there was
no apparent improvement in organizational systems especially in the external
financial and performance reporting area. The Authors measured the effectiveness of the training i.e.
whether a high rate of learning had taken place during the course, and whether
this had led to implementation of change for the better in the work place.
They developed seven effectiveness indicators from the needs/objectives
of the various stakeholders. These
were: selection and process criteria; course attributes (design, content, venue,
presenters); attendance rate; performance on the course; on the job
implementation of knowledge and skills gained; follow up and evaluation and
long-term benefits to the individual organization in particular and the AIDS
Service Organizations in general. These
indicators were in lieu of missing baseline performance indicators. The Authors also looked at major management and programming
issues in AIDS management and discussed the major strengths and weaknesses of
the management training programme. This
evaluation showed clearly how rapidly changing situations need flexibility in
training approaches. By the end of
the training session, several major issues and trends developed in the AIDS
programme area, resulting in the need for managers to acquire new skills and
knowledge, especially in the area of counseling, advocacy, lobbying,
fund-raising and community mobilization. Author: Smultylo, T.,
Earl, S., and Richardson, B. Title:
Origins of Achievements of the Navrongo Health Research Centre Source:
IDRC, Corporate services branch - Evaluation Unit Key words:
health research, Ghana Reviewer:
Karen T. Odhiambo, Nairobi University, Kenya Description:
[Documentation of a research centre that has facilitated
dramatic reductions in child mortality and morbidity as well as significant
health improvements in its region with modest but significant input by IDRC] The twelve-page report is an evaluation report on the
origins and achievements of the Navrongo health Research Centre located in the
West African nation of Ghana. Its mandate is to conduct applied health research
and has attracted international attention. The health research centre started
out in 1988 as a field site in Northern Ghana for a study on vitamin A
supplements for children funded by British ODA. Building on the census obtained
IDRC’s assistance to expand into research on child mortality and Malaria
prevention. Today NHRC is a world-class health research facility, which has
brought about dramatic reductions in child morbidity and mortality as well as
significant health improvements. The evaluation was carried out to review the historical
factors that influenced the institution’s origins in order to prepare for a
possibility of assisting NHRC to conduct an institutional self-assessment to
strengthening its capacity. The approach was based on face-to-face, telephone
and e-mail interviews with fifteen people associated with NHRC. The results show
that NHRC is influencing research in the southern regions and has propelled them
to the position of trainer. The research technologies applied have been
influential. Demographic surveillance is one of its recognized strengths and is
a model for other sites. The NHRC researchers present and publish their work
widely. At national level it influences government policy and public thinking.
The local population has had significant effects on their health. IDRC's contribution falls into four categories: financial,
technical, information technologies and networking. Funding has flourished,
programme staff encouraged and influenced NHRC staff to use a case control
methodology and to include a social-science research component. New
international scientific technologies such as Health Net/Satellite and GIS were
introduced. IDRC's professional contacts and linkages enabled it to offer
International scientific networks such as Health Net, Africa-GIS, Health-GIS,
Collaboration for mapping malaria Risk, MARA Network. In conclusion, the evaluators felt that relative to the
small amount of funding provided, IDRC has played an important role in NHRC's
research capacity and development over the years. |