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The state of emergency care in the Republic of Kenya

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The state of emergency care in the Republic of Kenya

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Approximately 580,000 km2 in size, the Republic of Kenya is as big as Botswana but only half the size of countries like South Africa, Mali, and Angola. Kenya is comprised of eight provinces: Central, Coast, Eastern, Nairobi, North Eastern, Nyanza, Rift Valley, and Western. The 2009 census revealed a population of over 38 million people, with a population density of approximately 66 persons per square kilometre. Majority of the population (68%) lives in rural areas, as compared with the sub-Saharan African average of approximately 62%. With a gross domestic product (GDP) per capita of US $1,600 in 2010, Kenya is considered a low-income country–– with 50% of the population living below the poverty line. HIV/AIDS disproportionately affects the country’s mortality and morbidity. Although its prevalence is higher than the regional average at 6.3% for people ages 15–49 years, it is much lower than many other sub-Saharan African countries. In addition to HIV/AIDS, tuberculosis, malaria, and diarrheal diseases are major killers. The burden of communicable diseases is high, with malaria as the leading cause of morbidity (30%), followed by respiratory diseases (24.5%). Malaria prevalence is 14%, and HIV prevalence is 7.4%, with a higher rate in women (8.5%) compared to men (5.6%). The non-communicable disease burden is also on the rise with diabetes prevalence at 3.3%, a threefold increase over the last 10 years. Mental health issues and road traffic injuries are also on the rise. Thirteen percent of school-age children aged 13–15 years are active cigarette smokers. These put Kenya in the company of other low-income countries predicted by the World Health Organization (WHO) to face the ‘‘double hump’’ burden of communicable and chronic disease over the next several decades.
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The state of emergency care in the Republic of Kenya
L’e
´tat des soins d’urgence en Re
´publique du Kenya
Benjamin Wachira
a,
*, Ian B.K. Martin
b
a
Accident and Emergency Department, Aga Khan University Hospital, Nairobi, Kenya
b
Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC, USA
Available online 21 October 2011
KEYWORDS
Emergency;
Kenya;
Development;
Care;
Service
Abstract Approximately 580,000 km
2
in size, the Republic of Kenya is as big as Botswana but
only half the size of countries like South Africa, Mali, and Angola. Kenya is comprised of eight
provinces: Central, Coast, Eastern, Nairobi, North Eastern, Nyanza, Rift Valley, and Western.
The 2009 census revealed a population of over 38 million people, with a population density of
approximately 66 persons per square kilometre. Majority of the population (68%) lives in rural
areas, as compared with the sub-Saharan African average of approximately 62%. With a gross
domestic product (GDP) per capita of US $1,600 in 2010, Kenya is considered a low-income coun-
try––with 50% of the population living below the poverty line. HIV/AIDS disproportionately
affects the country’s mortality and morbidity. Although its prevalence is higher than the regional
average at 6.3% for people ages 15–49 years, it is much lower than many other sub-Saharan African
countries. In addition to HIV/AIDS, tuberculosis, malaria, and diarrheal diseases are major killers.
The burden of communicable diseases is high, with malaria as the leading cause of morbidity (30%),
followed by respiratory diseases (24.5%). Malaria prevalence is 14%, and HIV prevalence is 7.4%,
with a higher rate in women (8.5%) compared to men (5.6%). The non-communicable disease bur-
den is also on the rise with diabetes prevalence at 3.3%, a threefold increase over the last 10 years.
Mental health issues and road traffic injuries are also on the rise. Thirteen percent of school-age
children aged 13–15 years are active cigarette smokers. These put Kenya in the company of other
low-income countries predicted by the World Health Organization (WHO) to face the ‘‘double
hump’’ burden of communicable and chronic disease over the next several decades.
ª2011 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights
reserved.
*Corresponding author.
E-mail address: benjamin.wachira@gmail.com (B. Wachira).
2211-419X ª2011 African Federation for Emergency Medicine.
Production and hosting by Elsevier B.V. All rights reserved.
Peer review under responsibility of African Federation for Emergency
Medicine.
doi:10.1016/j.afjem.2011.10.008
Production and hosting by Elsevier
African Journal of Emergency Medicine (2011) 1, 160–165
African Federation for Emergency Medicine
African Journal of Emergency Medicine
www.afjem.com
www.sciencedirect.com
Author's personal copy
D’une superficie de 580 000 km
2
environ, la Re
´publique du Kenya est aussi e
´tendue que le Bots-
wana mais est environ moitie
´moins grande que des pays tels que l’Afrique du Sud, le Mali et
l’Angola. Le Kenya compte huit provinces: Centre, Coˆ te, Est, district de Nairobi, Nord-est,
Nyanza, Rift Valley, et Ouest. Le recensement de 2009 faisait e
´tat d’une population de plus de
38 millions d’habitants, et d’une densite
´d’environ 66 personnes au kilome
`tre carre
´. La majorite
´
de la population (68%) vit en milieu rural, la moyenne pour l’Afrique sub-saharienne e
´tant de
62% environ. Avec un produit inte
´rieur brut (PIB) par habitant de 1 600 USD en 2010, le Kenya
est classe
´parmi les pays a
`faible revenu et 50% de sa population vit au-dessous du seuil de pauvrete
´.
Le VIH/Sida affecte disproportionnellement la mortalite
´et la morbidite
´du pays. Bien que le taux
de pre
´valence du VIH/Sida soit supe
´rieur a
`la moyenne re
´gionale de 6,3% des personnes aˆ ge
´es de 15
a
`49 ans, il est bien au-dessous de celui de nombreux autres pays d’Afrique subsaharienne. Outre le
VIH/Sida, la tuberculose, le paludisme et les maladies diarrhe
´iques constituent des tueurs majeurs.
Le poids des maladies transmissibles est conside
´rable, le paludisme e
´tant la principale cause de mor-
bidite
´(30%), suivi par les maladies respiratoires (24,5%). Le taux de pre
´valence du paludisme est de
14%, et celui du VIH de 7,4%, les femmes e
´tant plus affecte
´es (8,5%) que les hommes (5,6%). Le
poids des maladies non transmissibles augmente e
´galement, le taux de pre
´valence du diabe
`te e
´tant
de 3,3%, soit une multiplication par trois au cours des dix dernie
`res anne
´es. Les proble
`mes de sante
´
mentale et le nombre d’accidente
´s de la route sont e
´galement en hausse. Treize pour cent des enfants
d’aˆ ge scolaire, aˆ ge
´sde13a
`15 ans, sont des fumeurs actifs. Cela place le Kenya parmi les autres pays
a
`faible revenu qui devraient, selon l’Organisation mondiale de la sante
´(OMS) eˆ tre confronte
´sa
`un
« double » fardeau de maladie transmissible et chronique au cours des prochaines de
´cennies.
ª2011 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights
reserved.
Introduction
Approximately 580,000 km
2
in size, the Republic of Kenya is
as big as Botswana but only half the size of countries like
South Africa, Mali, and Angola.
1
Kenya is comprised of eight
provinces as shown in Fig. 1: Central, Coast, Eastern, Nairobi,
North Eastern, Nyanza, Rift Valley, and Western.
The 2009 census revealed a population of over 38 million
people, with a population density of approximately 66 persons
per square kilometre.
3
Majority of the population (68%) lives
in rural areas,
3
as compared with the sub-Saharan African
average of approximately 62%.
4
With a gross domestic prod-
uct (GDP) per capita of US $1,600 in 2010,
5
Kenya is consid-
ered a low-income country
6
–with 50% of the population
living below the poverty line.
5
HIV/AIDS disproportionately affects the country’s mortal-
ity and morbidity. Although its prevalence is higher than the
regional average at 6.3% for people ages 15–49 years,
7
it is
much lower than many other sub-Saharan African countries.
In addition to HIV/AIDS, tuberculosis, malaria, and diarrheal
diseases are major killers as shown in Table 1.
The burden of communicable diseases is high, with malaria
as the leading cause of morbidity (30%), followed by respira-
tory diseases (24.5%).
9
Malaria prevalence is 14%, and HIV
prevalence is 7.4%, with a higher rate in women (8.5%) com-
pared to men (5.6%).
7
The non-communicable disease burden is also on the rise
with diabetes prevalence at 3.3%, a threefold increase over
the last 10 years.
9
Mental health issues and road traffic injuries
are also on the rise. Thirteen percent of school-age children
aged 13–15 years are active cigarette smokers. These put Ken-
ya in the company of other low-income countries predicted by
the World Health Organization (WHO) to face the ‘‘double
hump’’ burden of communicable and chronic disease over
the next several decades.
10
Persistent poverty and low water
and sanitation standards have contributed to the endemicity
of diseases like cholera. There are also still pockets of neglected
tropical diseases, such as lymphatic filariasis.
9
Health care provision
Health services in Kenya are provided through a network of
over 6,600 health facilities countrywide.
11
Individual house-
Fig. 1 Map of Kenya.
2
The state of emergency care in the Republic of Kenya 161
Author's personal copy
holds remain the largest contributors of health funds, at
35.9%, followed by the government, and then private donors,
who contribute approximately 30%.
12
The public sector sys-
tem accounts for about 51% of these facilities, with the Minis-
try of Health and parastatal organisations being the major
players. The private sector delivers approximately one-third
of the outpatient care and 14% of inpatient care in the coun-
try,
13
through private, for-profit organizations, non-govern-
mental organizations (NGOs), and faith-based groups.
The Kenya Essential Package for Health (KEPH)
14
is de-
signed as an integrated collection of cost-effective interven-
tions to satisfy the demand for prevention and treatment of
commons diseases and injuries. The KEPH system delivers
comprehensive healthcare across six levels of care as shown
in Fig. 2:
Community health units organize activities focused on dis-
ease prevention and control. These efforts serve to reduce dis-
ability, morbidity, and mortality as well as to expand family
health services, such as family planning, maternal, child, and
youth services.
Dispensaries and clinics comprise approximately 80% of
the health care system
11
and are staffed by registered nurses
who work under the supervision of a nursing officer at the
respective health centre. These facilities provide outpatient ser-
vices for patients with simple ailments, such as influenza,
uncomplicated malaria, and skin infections.
Health centers, maternities, and nursing homes comprise
about 15% of health services in Kenya.
11
Generally, clinical
officers staff and administer these facilities. At this level of
care, additional outpatient services (including minor surgery
and limited dental services), limited inpatient services (includ-
ing uncomplicated deliveries), health education, and labora-
tory services (including HIV testing) are provided to patients.
Primary hospitals are managed by medical superintendents,
who are physicians with or without postgraduate training.
These hospitals provide quality clinical care by a staff more
skilled than that of the health centres and dispensaries. Pri-
mary hospitals offer twenty-four hour services and provide
more comprehensive services, such as major surgery and inpa-
tient care not available at the health centres.
At the fifth level of the KEPH sit secondary hospitals.
These facilities provide clinical services in all disciplines,
including emergency services as well as intensive care and
high-dependency care units. Secondary hospitals also serve
as clinical sites for training health care personnel, such as
nurses and medical interns.
Tertiary hospitals are at the apex of the health care system,
providing sophisticated diagnostic, therapeutic, and rehabilita-
tive services. The two tertiary hospitals are Kenyatta National
Hospital in Nairobi and Moi Referral and Teaching Hospital
Table 1 Ten major causes of death and years of life lost due to
disease in Kenya in 2002.
8
Causes Deaths (%) Years of
life lost
HIV/AIDS 38 40
Lower respiratory infections 10 11
Diarrheal diseases 7 8
Tuberculosis 5 5
Malaria 5 6
Cerebrovascular disease 4 1
Ischemic heart disease 4 1
Perinatal conditions 4 5
Road traffic accidents 2 2
Chronic obstructive pulmonary disease 2 1
Fig. 2 KEPH levels of care.
14
162 B. Wachira, I.B.K. Martin
Author's personal copy
in Eldoret in western Kenya. The equivalent private referral
hospitals are Nairobi Hospital and Aga Khan University Hos-
pital both located in Nairobi. In addition to, providing train-
ing to health professionals, public tertiary hospitals serve as
research centres.
Mechanisms do exist in Kenya to facilitate transition of pa-
tients from one level of care to another; however, implementa-
tion varies widely across the country. According to the 2004
Service Provision Assessment (SPA), about 9 out of 10 pri-
mary hospitals, 6 out of 10 health centres, and very few dispen-
saries under government management had on-site transport
available for emergencies.
15
On the other hand, districts re-
ported that close to 86% of the NGO and private health facil-
ities had on-site transport available for emergencies.
Inter-facility referrals can be difficult in more remote areas
of the country. Several districts in Kenya are not connected to
the cellular network, and others have nearly impassible roads,
particularly during the rainy season. To compound the prob-
lem, only 16% of health facilities across the country have
and use referral forms essential to the communication of vital
patient information
15
; half of facilities in Nairobi province
have referral forms, in contrast to only 1% of in North Eastern
province.
Emergency care
The American College of Emergency Physicians in a 2008
statement defined Emergency Medicine (EM) as: Emergency
medicine is the medical specialty dedicated to the diagnosis
and treatment of unforeseen illness or injury. It encompasses
a unique body of knowledge as set forth in the ‘‘Model of
the Clinical Practice of Emergency Medicine.’’ The practice
of emergency medicine includes the initial evaluation, diagno-
sis, treatment, and disposition of any patient requiring expedi-
tious medical, surgical, or psychiatric care. Emergency
medicine may be practiced in a hospital-based or freestanding
emergency department (ED), in an urgent care clinic, in an
emergency medical response vehicle, or at a disaster site.
The delivery of emergency care in Kenya is quite different
from, and in most instances, less sophisticated than that of
countries with a well-developed specialty of Emergency Medi-
cine. Arnold describes three stages of national Emergency
Medicine development: mature; developing; and underdevel-
oped.
16
Countries like the United States (US), Australia, and
the United Kingdom (UK) have ‘‘mature’’ systems of emer-
gency care and as such can serve as ‘‘mentors’’ to other coun-
tries with bourgeoning emergency care systems. Much of
Europe and the Middle East are considered to have a ‘‘devel-
oping’’ system of emergency care. Most of Africa, with the
exception of South Africa, falls into the ‘‘underdeveloped’’ cat-
egory in terms of national EM development.
Arnold also outlines a country’s maturation of Emergency
Medicine along four schemes: patient care systems; manage-
ment systems; specialty systems; and academic EM.
16
As per
these descriptions, Kenya’s system for emergency care delivery
clearly falls into the ‘‘underdeveloped’’ category. As an exam-
ple, Kenya offers no training opportunities in the specialty of
Emergency Medicine in contrast to ‘‘developing’’ and ‘‘ma-
ture’’ countries which typically do. Similarly, Kenya has no or-
ganized national system for trauma care, while countries in the
‘‘mature’’ stage do.
Emergency Medical Services (EMS)-based
Most patients are transferred to hospitals by private means,
for instance by car, truck, or taxi, among others. Few present
to emergency centers (ECs) by ambulance (whether truck or
aircraft) given their scarcity and the lack of a well-connected,
reliable central dispatch system. A study done in an emergency
centre in South Africa demonstrated that most patients (60%)
used their own means to reach the emergency centre.
17
By Ar-
nold’s description, this again places Kenya’s national EM
development in the ‘‘underdeveloped’’ column. Nations with
‘‘mature’’ and ‘‘developing’’ patient care systems, usually rely
heavily on ambulance services for transport.
16
Established in 1928, St. John Ambulance is the only public
provider of emergency medical services in Kenya.
18
With only
ten ambulances across all of Kenya (with five in Nairobi at
headquarters), they respond to patients in need at no cost.
19
Private EMS plays a limited role, too, as they are mostly lo-
cated in Nairobi and only serve patients who can afford to pay.
The Kenya Council for Emergency Medical Technicians
(KCEMT) was established in 2008 and is now the sole profes-
sional body setting national standards, regulating EMS train-
ing, and lobbying for formal recognition of EMTs in Kenya.
According to its secretary, KCEMT has trained and certified
approximately 1800 managers of first responders, including
ambulance, military, police, and fire services, as well as district
and provincial administrative and government officials since
June 2008.
Hospital-based
Most Emergency Centres, or ECs, are staffed by clinical offi-
cers who work independently or alongside medical officers
(physicians without postgraduate training) to provide urgent
and emergent care to largely rural populations. Clinical offi-
cers are not physicians but health care providers with three
years of rigorous training following the medical model. And
like medical officers, they lack specific training in the specialty
of Emergency Medicine.
Clinical officers are trained in basic sciences, nursing care,
and have clinical rotations in most inpatient hospital depart-
ments.
20
On graduation, they receive a diploma in clinical
medicine, surgery, and community health and work as full-
time interns for one year before getting a license to practice
medicine independently. Internship involves three-month
supervised rotations in the major clinical departments, includ-
ing EC. The Kenya Medical Training College offers post-basic
courses to clinical officers, leading to a specialized qualification
in several areas, but EM is not one of them.
Kenyan ECs are often poorly equipped and overcrowded.
Patients with different types of complaints are evaluated in dif-
ferent parts of the unit by healthcare providers of different
medical specialties. For instance, a patient presenting to EC
with a complaint of abdominal pain will be cared for by a sur-
geon, while a woman with vaginal bleeding might be evaluated
by a gynecologist. In contrast, emergency physicians in the US
care for all patients, without regard to complaint, who present
to the emergency department. US emergency physicians will
involve consultant specialists as needed.
With no EM-trained physicians or EC directors, no na-
tional system for trauma care or transfers, Kenya is certainly
The state of emergency care in the Republic of Kenya 163
Author's personal copy
considered ‘‘underdeveloped’’ in terms of its national EM
development as per Arnold’s classifications. Said another
way, Kenyan patients presenting to ECs with acute, time-sen-
sitive illness and injury are cared for largely by undertrained,
non-physician healthcare providers with no specific prepara-
tion in Emergency Medicine.
The need for development of Emergency Medicine in Kenya
Emergency medicine as a specialty has developed rapidly in
certain parts of the world (e.g., Australia, Canada, UK, and
US), but it remains largely immature in developing nations like
Kenya. With more trauma and chronic illness, as well as high
levels of communicable diseases and maternal/child mortality,
Kenyan EC units sit at the intersection of these challenges.
That is, like in countries with ‘‘mature’’ systems of emergency
care, Kenyan EC units are well positioned to manage a rapidly
growing population of patients and to provide immediate and
time-sensitive care. Given this unique positioning, the overall
healthcare system in Kenya, and more importantly Kenyan pa-
tients, would benefit from additional resources to aid in the
development of EM as a specialty there.
Despite patient demand for EM services
21
and clear evi-
dence that well-established systems of emergency care can re-
duce mortality and morbidity from many common
conditions in the developing world
22
, government officials cur-
rently have no plans to develop EM as a specialty in Kenya.
Although there are well-formulated guidelines for specific dis-
ease states which span many aspects of clinical emergency care
(for example, malaria, AIDS, head injury, etc.), they do not at-
tempt to prioritize the care or to guide the overall structure
and management of the EC.
23–25
None of the medical universities or colleges has EM train-
ing programs, though one private academic hospital is cur-
rently developing faculty to help initiate EM as a specialty in
Kenya. The Kenya Medical and Dentists Board (KMDB) does
not recognize Emergency Medicine as a speciality, and there-
fore, even foreign-trained emergency physicians cannot be reg-
istered by the KMDB as such.
One of the possible first steps to developing EM in Kenya
would be to lobby for the recognition of the speciality by the
KMDB to allow for the registration of foreign-trained emer-
gency physicians who would form local faculty to commence
training of health care providers in resource-appropriate as-
pects of emergency medicine.
Although training Kenyan physicians to practice as emer-
gency physicians is the ultimate goal, EM residency programs
take long and are expensive to develop and only allow for the
training of a handful of specialists at a time. On the other
hand, training the current EC providers, including registered
nurses and clinical officers in targeted, resource-appropriate
emergency care through short didactic and practical courses
should be an important early step in developing EM in Ken-
ya. In an observational study conducted in Kenya’s emer-
gency centres, most critically ill patients were left to the
admitting teams to initiate resuscitative care, and only minor
conditions were handled in the emergency centre.
26
These
didactic and practical courses would not only potentially im-
prove care in these Kenyan facilities but would also serve to
generate the necessary interest in and support for the
speciality.
As an intermediate step, interested medical and clinical offi-
cers could be awarded diplomas in emergency medicine after
an abbreviated training. A diploma in EM would take a short-
er time to complete, and this strategy has the advantage of
employing a successful model of education already established
here sub-Saharan Africa. As training of medical and clinical
officers has served as an important stop-gap measure in other
understaffed specialties, it could do the same in a bourgeoning
specialty of emergency medicine.
Conclusion
Kenya, a country of nearly 40 million people, provides health-
care to its citizens through a tiered system called the Kenya
Essential Package for Health. This network is comprised of
public and private health facilities with increased services at
each subsequent tier.
Like other low-income countries, Kenya is plagued by com-
municable diseases, like respiratory infections, HIV, and ma-
laria. And with growing influence from occidental countries,
smoking and obesity rates are on the rise. This means countries
already burdened with infectious diseases have an ever increas-
ing burden of chronic diseases, like hypertension and diabetes.
In a country with few financial resources, addressing the public
health needs for both communicable and chronic diseases can
be overwhelming.
Despite KEPH, there is little sophistication in the delivery
of emergency care in Kenya, and this is true of most African
nations. The ECs (often poorly equipped) that do exist are lar-
gely staffed by non-physician personnel with no specific train-
ing in Emergency Medicine. Kenya stands ready to improve its
delivery of emergency care with mentorship from healthcare
professionals/organizations from countries in which Emer-
gency Medicine is mature as a specialty. This is certainly worth
the investment of resources, as the development of a more ad-
vanced system of emergency care has been shown to reduce
morbidity and mortality.
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The state of emergency care in the Republic of Kenya 165
... Emergency health conditions represent a high burden of disease and improved care provides an opportunity for a healthier Kenya [1,2]. Emergent conditions account for substantial morbidity and mortality in low and middle-income countries (LMICs) yet care for these conditions has been a neglected area of health systems in much of the world [3][4][5]. ...
... The last decade has seen increased focus and development of emergency medicine in the Republic of Kenya. Since the last publication regarding the state of emergency medical care in Kenya one decade ago, there have been several developments to the country's approach to emergency medical care [1]. This article provides an update regarding advances to emergency care systems, education, and policy in Kenya, while also proposing advancement targets for the future of emergency care in the country. ...
Article
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Kenya is a rapidly developing country with a growing economy and evolving health care system. In the decade since the last publication on the state of emergency care in Kenya, significant developments have occurred in the country's approach to emergency care. Importantly, the country decentralized most health care functions to county governments in 2013. Despite the triple burden of traumatic, communicable, and non-communicable diseases, the structure of the health care system in the Republic of Kenya is evolving to adapt to the important role for the care of emergent medical conditions. This report provides a ten-year interval update on the current state of the development of emergency medical care and training in Kenya, and looks ahead towards areas for growth and development. Of particular focus is the role emergency care plays in Universal Health Coverage, and adapting to challenges from the devolution of health care.
... Most victims in emergencies get to hospitals by private means, for instance by car, motorcycles, or taxis, among others. Few arrive to emergency centers by ambulances given their scarcity and the lack of a well-connected, reliable central dispatch system that enables easy contact in an emergency (Benjamin & Ian, 2011). Table 4.1 shows the Rate of use of some major form of transportation during emergencies. ...
Conference Paper
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Commercial banks play a key role of financial intermediation between depositors and borrowers prompting a more productive allocation of resources and faster economic growth in the economy of any nation. Kenya‘s Vision 2030 economic blueprint (2008 – 2030) aims to transform Kenya into a middle-income country. The Government of Kenya thorough CBK has provided an enabling environment, supporting legal and regulatory framework like regulation of interest rates to ensure that commercial banks contribute towards realization of vision 2030 prosperous economy. In order to play their intermediation role, commercial banks have to be profitable and have thus invested heavily in e-commerce solutions. Despite these initiatives by the government, commercial banks have presented mixed results in terms of their performance. This study will therefore investigate the effect of transaction capability on performance of commercial banks in Kenya. This will be a desk top review and will be anchored on UTAUT theory. It is anticipated that a detailed conceptual framework will be developed to guide future research. The findings of the study will provide valuable insights and a basis for understanding the effect of e-commerce transaction capability on performance of commercial banks in Kenya. Bank managers and other firm‘s policy makers will benefit from the pool of knowledge advanced by the findings of this study by understanding the effect of e-commerce transaction capability on performance of a firm. This will assist them to formulate sound policies regarding leveraging their key e-commerce resources in creating and sustaining competitive advantage that leads to improved performance.
... The study findings validate the HRT premise that embracing the five HRO mindfulness processes (preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise) can support an organizations objective for a highly reliable performance. Despite the study findings that the EMS organizations in Nairobi County possess characteristics of an HRO, research findings from previous studies (Mugambi, 2008;Wachira & Martin, 2011;Thompson, 2013;Wachira & Smith, 2013;Ochieng, 2015;Gichuki, 2019) suggest that the EMS response to past Mass Casualty Incidents in Nairobi County has been unsatisfactory. ...
... Scarcity of EMS resources including ambulances, medical supplies, and human resources were other system related barriers to access identi ed by this study, as a result of this commercial transportation methods were the most frequently used means of emergency transportation in the community. Similar ndings have been reported across Sub-Saharan Africa [6,8,23,24]. The participants of this study stressed that increasing the number of ambulances was important in order to meet the demands of the community. ...
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Background: African nations experience a significant proportion of the global burden of death and disability. The provision of prehospital emergency care has been shown to partially reduce excess morbidity and mortality. However, access to prehospital care in Africa is still limited. This study sought to identify barriers to access prehospital care in the city of Jimma, Ethiopia. Methods: This is an interview-based qualitative study of key prehospital stakeholders in Jimma, conducted in February 2018. A purposive sample of individuals from the community and local ambulance organizations was selected for interviews. Interviews were conducted in local languages, translated into English, and then coded for consistent themes. Results: All respondents felt that prehospital care was difficult to access and therefore infrequently utilized. This was due to a combination of a limited number of ambulances, the lack of a toll-free emergency number, the lack of a single organized EMS system, a lack of uniform prehospital care protocols, inconsistent and limited training of ambulance crews, public mistrust of the existing system, poor road infrastructure, and limited public understanding of the role of prehospital care. Respondents suggested that establishment of a formalized prehospital care system, investment in infrastructure, establishment of a toll-free emergency number, public awareness campaigns, and more widely available emergency medical training were feasible solutions to these current barriers to access. Conclusion: Multiple barriers to accessing prehospital care were identified in Jimma. Establishing a formalized, well-resourced prehospital system in parallel with improving community capacity and knowledge building were suggested solutions to improve access. Hence, interventions to improve prehospital emergency care delivery should ideally target these identified barriers and proposed solutions.
... A most recent report shows a further decline from 488/100,000 (KDHS, 2008/9) to 362/100,000 live births (KDHS, 2014). However, the situation could be worse in counties with marginalized vulnerable communities (Wachira & Martin, 2011: Saad-Haddad et al., 2016. The more economically challenged and marginalized a mother is, the higher the risk of death. ...
Article
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Purpose: To determine cultural competence of health care workers on maternal health care service utilization among mothers of Mt. Elgon Constituency in Bungoma County. Methodology: A descriptive-analytical cross-sectional study design was adopted using mixed methods for data collection. Cultural competence tool was used to assess health care workers cultural competence. Qualitative data was collected using key informant interviews (KII) and focus group discussion (FGD). Data entry and analysis was done using SPSS Version 25 software. Descriptive and inferential statistical analyses were used. Bivariate and multivariate logistic regressions were applied and odds ratio used to determine the strength of association. A p-value of ≤ 0.05 was considered as statistical significance threshold. Findings: Unemployment (OR: 0.6; 95% CI: 0.4 – 0.9; p = 0.02); lack of mobile clinic (OR: 0.7; 95% CI: 0.4 – 1.0; p = 0.06 ); use of interpreter (OR: 0.2; 95% CI: 0.01 – 0.81; p = 0.02); service provided in public facilities (OR: 0.5; 95% CI: 0.3 – 0.8; p = 0.004); being too busy (OR: 0.5; 95% CI: 0.3 – 0.9; p = 0.02); consulting health care workers (OR: 0.5; 95% CI: 0.2 – 0.9; p = 0.03); not consulting elders (OR: 0.7; 95% CI: 0.4 – 1.0; p = 0.08) and culturally incompetent ( 100%) were significantly associated with utilization of maternal and child health services. The determinants of maternal health care service utilization in Mt. Elgon Sub-County are women who are employed (OR: 2.8; 95% CI: 1.1 – 7.3; p=0.03) and cultural incompetence of health care workers (100%). A unique contribution to theory, practice, and policy: The study findings have identified cultural competence gaps among health care workers which need to be addressed by policy makers to increase utilization in the study area and other similar environment
... A study looking at the state of healthcare in all Kenyan emergency departments found that most patients are transferred to hospital by public means, including taxi, buses, and private cars. 14 The above findings were also reflected in the responses to the knowledge questionnaire: 51.5% of the respondents would call the doctor first rather than calling the ambulance, a finding which has consistently been found to be a delay factor in recent reviews. 7 A total of 68.0% said they would drive or have someone drive them to hospital, and only 23.3% would call an ambulance. ...
Article
The delivery of definitive acute stroke care in Africaremains low due to prehospital barriers, and these are known to be country-specific. There have been no studies on elucidating these barriers in Kenya. Objectives We sought to identify the nature of barriers to acute stroke care for patients presenting to our hospital in Nairobi, Kenya. Materials and Methods We conducted a prospective cross-sectional study atour tertiary regional referral center from August 2018 to March 2019 for patients presenting with an acutestroke. We consented participants (patients or their registered next-of-kin) to fill out a questionnaire on their journey from stroke-onset to the ward bed, and about their knowledge about stroke. Results We recruited 103 participants. Only 25.2% arrived to hospital within 3.5 h (early arrival) of stroke onset. The significant factors causing delay were:distance from hospital, traffic, visiting another hospital first, and lack of transport vehicle. Factors significantly associated ( P<.05) with early arrival were: older age, non-African ethnic origin, bystander present at stroke onset, living near (<15km) the hospital, and knowledge of stroke. Almost 80% believed stress was a major risk factor and that dizziness was a cardinal symptom. Only 50% knew of the availability of thrombolysis/thrombectomy and their roles in stroke treatment, and only 37.9% knew the correct time limits for these. Conclusions We identified a number of prehospital barriers to reaching hospital on time for definitive stroke treatment, which have implications on the structure of emergency services for stroke in our city. Our study also revealed interesting observations on the public’s understanding about stroke, calling for a tailored public awareness campaign to improve stroke knowledge.
Article
This article that is located within the alternative knowledge systems paradigm, discusses both the ancient and modern concepts of lifelong learning in relation to Africa’s development. It identifies ancient Greece’s education and African traditional education as two ancient lifelong learning typologies relevant to the current discussion. Ancient Greece’s education is a forerunner to modern education while African traditional education is one typology of education that remains relevant to African developmental aspirations. The modern concept of lifelong learning highlighted in this article is the one made popular by the United Nations Educational Scientific and Cultural Organisation (UNESCO). The article reviews the socialisation processes and worldviews prevalent within the West and Africa alongside the 50%, 40% and 7% Africa’s best primary, secondary and tertiary education success rates respectively and concludes that incongruity between the two socialisation processes and worldviews are responsible for this nearly two-century-old modest contribution of modern education to Africa’s development. Consequently, the article concludes that only a combination of both modern and African lifelong learning would expedite Africa’s socio-economic development.
Article
Emergency Medical Service (EMS) is the system that organizes all aspects of medical care provided to patients in the pre-hospital environment and emergency department within hospitals. It comprises agencies and organizations (both private and public), communication and transportation networks, hospitals, highly trained professionals and a public aware on how to respond in emergencies. Kenya needs robust EMS due to the high prevalence of acute medical events such as COVID-19, natural and man-made disasters. The objective of this study was to assess utilization of ambulance services in Nairobi County. The study design was descriptive cross-sectional, using quantitative and qualitative research methods. Data was collected using interviewer-administered semi-structured questionnaires and key in-depth interviews from 14 ambulance services, 19 Emergency Care Centers (ECC), and community. Thirty-nine key informants were sampled using purposive sampling technique and 101 community members sampled using simple random sampling technique from 10 sub-counties. Data tools were pretested at Mukuru Kwa Njenga, a populous slum in Nairobi County. Approval to carry out the study was granted by the Ministry of Health, Kenya. Qualitative data was analyzed using NVIVO12 and quantitative data analyzed using descriptive statistics by use of SPSS vs 25 software. Findings are represented as frequencies and percentages. There were 14 ambulance service providers in the Nairobi Metropolitan Services area with a total of 42 ambulances. Forty-one ambulances were facility-based ambulances. All ambulance services had emergency numbers, and only 3 had short-toll free ambulance access numbers. There were 9 different ambulance dispatch centers in the county. Five ambulance services did not have a dispatch Centre. Public members were the first to assist in in 79% emergencies. There was low public awareness on available pre-hospital emergency care services and tollfree lines for emergency services. Ambulances utilization was also low.
Book
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This book examines the idea of a fundamental entitlement to health and healthcare from a human rights perspective. The volume is based on a particular conceptual reasoning that balances critical thinking and pragmatism in the context of a universal right to health. Thus, the primary focus of the book is the relationship or contrast between rights-based discourse/jurisprudential arguments and real-life healthcare contexts. The work sets out the constraints that are imposed on a universal right to health by practical realities such as economic hardship in countries, lack of appropriate governance, and lack of support for the implementation of this right through appropriate resource allocation. It queries the degree to which the existence of this legally enshrined right and its application in instruments such as the International Covenant on Economic, Social and Cultural Rights (ICESCR) and the Universal Declaration of Human Rights (UDHR) can be more than an ephemeral aspiration but can, actually, sustain, promote, and instil good practice. It further asks if social reality and the inequalities that present themselves therein impede the implementation of laudable human rights, particularly within marginalised communities and cadres of people. It deliberates on what states and global bodies do, or could do, in practical terms to ensure that such rights are moved beyond the aspirational and become attainable and implementable. Divided into three parts, the first analyses the notion of a universal inalienable right to health(care) from jurisprudential, anthropological, legal, and ethical perspectives. The second part considers the translation of international human rights norms into specific jurisdictional healthcare contexts. With a global perspective it includes countries with very different legal, economic, and social contexts. Finally, the third part summarises the lessons learnt and provides a pathway for future action. The book will be an invaluable resource for students, academics, and policymakers working in the areas of health law and policy, and international human rights law.
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To describe the case mix, interventions, procedures and management of patients in public emergency departments (ED) in Kenya. An observational study over 24 h, of patients who presented to 15 public ED during the 3-month period from 1 October to 31 December 2010. The study was conducted across Kenya in two national referral hospitals, five secondary level hospitals and eight primary level hospitals. All patients presenting alive to the ED during the 24-h study period that were seen by a doctor or clinical officer were included in the study. A data collection form was completed by the primary investigator at the time of the initial ED consultation documenting patient demographics, presenting complaints, investigations ordered, procedures done, initial diagnosis and outcome of ED consultation. Data on 1887 patient presentations were described. Adults (≥13 years) accounted for the majority (70%) of patients. Two peak age groups, 0-9 and 20-29 years, accounted for 27% and 25% of patients, respectively. Respiratory and trauma presentations each accounted for 21% of presentations, with a wide spread of other presentations. Over half (58%) of the patients were investigated in the department. 385 patients received immediate treatment in the ED before discharge. Fewer than one in three patients admitted or transferred to specialist units received any therapy in the ED. ED in Kenya provide care to an undifferentiated patient population yet most of the immediate therapy is provided only to patients with minor conditions who are subsequently discharged. Sicker patients have to await transfer to wards or specialist units to start receiving treatment.
Article
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To describe the demographics, referral mechanism and outcome of the emergency consultation in patients presenting to a secondary hospital emergency centre (EC). An observational study of patients presenting to an EC in a 1-month period from 19 November to 20 December 2007. New Somerset Hospital, Cape Town, South Africa. All patients presenting alive to the EC during the study period who were seen by an EC doctor. A data collection form was completed by EC doctors at the time of the initial EC consultation documenting patient demographics, time and delay periods, South African Triage Score (SATS), initial diagnosis, transport and referral mechanisms and outcome of EC consultation. Data on 2646 patient presentations were described with a mix of SATS acuity levels (green: routine care; yellow: urgent; orange: very urgent; red: immediate), with more than one-third of presentations scoring an orange or red SATS. Most patients presented in the daytime, with an increase in more ill patients (higher SATS) later in the day and at night. The peak age group was 20-40 years, with 39% resident in informal settlements within 15 km of the hospital. The initial diagnosis was trauma in 26% of presentations, with a wide spread of other presentations. Patients were transported by ambulance to the EC in 39% of presentations, 41% were self-referred and 41% were referred by a primary health care practitioner. Fifty-three percent of presentations were either admitted to hospital or kept in the EC for further investigations, and the remainder were discharged from the EC. Clear trends are seen for patient demographics and temporal attendance patterns which are important for resource allocation and planning. Many low-acuity patients, largely non-referred, are being seen in the EC and should be managed by primary health care level staff outside the EC.
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Prevention is a core value of any health system. Nonetheless, many health problems will continue to occur despite preventive services. A significant burden of diseases in developing countries is caused by time-sensitive illnesses and injuries, such as severe infections, hypoxia caused by respiratory infections, dehydration caused by diarrhoea, intentional and unintentional injuries, postpartum bleeding, and acute myocardial infarction. The provision of timely treatment during life-threatening emergencies is not a priority for many health systems in developing countries. This paper reviews evidence indicating the need to develop and/or strengthen emergency medical care systems in these countries. An argument is made for the role of emergency medical care in improving the health of populations and meeting expectations for access to emergency care. We consider emergency medical care in the community, during transportation, and at first-contact and regional referral facilities. Obstacles to developing effective emergency medical care include a lack of structural models, inappropriate training foci, concerns about cost, and sustainability in the face of a high demand for services. A basic but effective level of emergency medical care responds to perceived and actual community needs and improves the health of populations.
Article
Emergency medicine is being established as a unique and independent specialty throughout the world. Two major models of emergency care delivery exist in the world today: the Anglo-American and the Franco-German model. Most countries developing new systems of emergency care are following the Anglo-American model and are recapitulating the sequence of steps taken to establish the systems of emergency medicine in the United States. The most important step in the development of emergency medicine in other countries is the recognition that emergency medicine incorporates a unique body of knowledge requiring specialized practitioners or emergency physicians. A global network of international emergency medicine is assisting the development of emergency medicine worldwide and now includes international organizations, academic institutions, and individuals in countries where emergency medicine is mature and their counterparts in countries where emergency medicine is developing. The multilevel exchange of information through various modalities, such as international conferences, physician exchange programs, and print or electronic media, is playing a vital role in the search for internationally applicable systems of emergency care.
Article
Following 18 months of multi-stakeholder consultations, and two days of tense negotiations at the 57th World Health Assembly in May, the Global strategy on diet, physical activity and health was finally--and unanimously--adopted by WHO Member States. The adoption of the nonbinding strategy opens the way for policy-makers to develop new initiatives to tackle the global rise in chronic noncommunicable diseases (NCDs) such as cardiovascular diseases, a rise that has been particularly marked in the developing world. "Noncommunicable diseases are imposing a growing burden upon low-and middle-income countries, which have limited resources and are still struggling to meet the challenges of existing problems with infectious diseases," said Dr Catherine Le Gales-Camus, Assistant-Director General at WHO's department of Noncommunicable Diseases and Mental Health. WHO estimates that non-communicable diseases--including cardiovascular diseases, diabetes, cancers and obesity-related conditions--now account for 59% of the 56.5 million deaths which occur globally every year and almost half (45.9%) of the global burden of disease. Traditionally associated with developed countries, some 80% of all cardiovascular disease-related deaths now occur in low- and middle-income countries. An estimated 171 million people were affected by diabetes in 2000, two-thirds of which live in developing countries. By the year 2030, WHO predicts that there will be 284 million people with diabetes living in developing countries. Worst affected countries are China where there were 20.8 million cases in 2000 and India where in 2000, there were 31.7 million cases of diabetes. Obesity, commonly associated with industrialized nations--in the US about 30% of adults are obese--is becoming a major problem in some developing nations too. According to data from the WHO Global NCD InfoBase Online, in Egypt between 1991 and 1994, 56% of men and 45% of women in Cairo's urban region were obese. In South Africa, 30% of women were obese in 1998, rising to 46% for women aged between 55 and 64 years. More than one billion adults worldwide are currently overweight, of which 300 million are clinically obese. The majority of cardiovascular diseases can be attributed to major risk factors such as high cholesterol, high blood pressure, low fruit and vegetable intake, inactive lifestyle and tobacco use. Worldwide people are consuming more foods that are nutritionally poor but energy-dense--high in sugar and/or saturated fats--or excessively salty. "In developing countries, the change in nutritional intake combined with increasingly sedentary lifestyles resulting from food market globalization and increasing urbanization, has led to the emergence of chronic diseases as a major new health threat," said Amalia Waxman, Project Manager for the Global strategy on diet, physical activity and health. "In Viet Nam for example, the shift from bicycles to motorbikes as the most popular form of transport has led to a dramatic fall in levels of physical activity contributing, together with dietary changes and tobacco consumption, to a rise in noncommunicable disease risk factors whilst the country is still trying to bring malnutrition under control. …
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