Health information for district level planning: a cross-sectional household survey in rural Kenya

Health care planning and management in sub-Saharan Africa is being decentralised, and health information systems need to meet new needs. This study in rural Kenya explored the feasibility of a cross-sectional household health interview survey to help district-level health planning. Heads of 390 households were interviewed about health-related factors like housing standard, water supply, sanitation, recent illness, and health care use. Half of all households lived on farming. Access to water sources was poor, but latrine coverage was high. Of all disease episodes 26% were respiratory, 18% gastrointestinal and 10.5% malaria. Rates of illness episodes were low (1.0 day of illness/person/30 days), and 40% of episodes were taken to a modern service provider like a dispensary, health centre or hospital. The survey generated much information on household characteristics, illness episodes and action taken, data that was not available through the routine health information system. Survey costs were estimated at 15 US cents per resident in the project area, a large proportion of which was absorbed by computerized data processing, but may be reduced to about half. If conducted once every three or four years, a survey of this kind would be affordable within the ordinary recurrent district health budget and would provide useful planning and management information.

Patient attitudes to major surgery in rural Kenya

In this Kenyan study of patient perceptions of major surgery and involvement in decisions to operate, the attitudes of 89 female and 23 male patients who had undergone major surgery at a district hospital were studied. Semi-structured interviews were conducted in the wards by a social worker who had no employment or other relationship with the hospital. In 48 cases the decision about the operation was taken jointly by patient and doctor, while in 49 cases the decision was reportedly taken by the doctor alone. In 81 cases (64 female and 17 male) a relative or friend accompanied the patient to hospital. Only 21 patients reported being told details about the operation before the event. One quarter of the patients (housewives and school children) admitted feeling afraid or nervous prior to the operation while two-thirds reported having felt either confident or resigned about it. Ninety-eight patients characterized the care as good while seven felt it was poor.

Minor surgery and resources at small clinics in rural Kenya

The output of minor surgery at 36 government and 49 non-government clinics in a rural Kenyan district was recorded over a period of one year and then compared with the surgery-related resources (equipment, supplies and trained staff) at the same clinics. The mean monthly numbers of operations varied between 2.8 and 7.0 at different resource levels, but we found no association between the surgical operation output of each clinic and its total surgery-related resources. When examining the resource components separately, we found a weak positive association between output and the presence of equipment but no association between output and supplies or trained staff. Other factors than resources, such as the quality of basic training or the preferences of individual health workers, may explain the large surgical output variations between clinics. They should be explored through further studies.

Rates of major surgery by age and sex in a rural district in Kenya

All major surgical operations performed during 1 year in Meru district, Kenya, were recorded. The district, with a population of 1.3 million, had five hospitals and two nursing homes where major surgery was performed. Over 3400 major operations were recorded: Caesarean section (129.0 operations/100,000 population), tubal ligation (39.4), laparotomy (14.0), hysterectomy (5.0), open reduction of fracture (4.3) and hernia repair (6.3). The total major surgery rate was 263/100,000 year: 88/100,000 males and 434/100,000 females. Of all major operations, 83.5% were performed on females, the most common being Caesarean section, tubal ligation, laparotomy, eye or lens removal and hysterectomy. Most frequent major operations on males were laparotomy, eye or lens removal, hernia repair, gastro-intestinal surgery and prostatectomy. Most major surgery (68.1%) was on young and middle-aged adults; only 7.7% was performed on children aged < 15 years even though these made up half of the population. Rates increased with age, and there were modest male/female differences except for very high rates of obstetrical surgery on young women. There is need to expand the district's capacity for major surgery and also to prevent more conditions requiring surgery, for example by improving sexual- and reproductive-health education, making family planning services more easily available among sexually active adolescents, and by initiating more aggressive prevention programmes against injuries. Although population-based operation rates, totally and by sex and age-group, are useful indicators for monitoring service output, current reporting is inadequate. One step towards improvement would be to require that every hospital reports, annually to the district level, all major operations by kind and by age and sex of the patient.

Exploring the interface between first and second level of care: referrals in rural Africa

The studies aimed to determine the referral rate, the characteristics of patients referred, the reasons for referral and, in a sub-sample, its outcome. Study I recorded data on 602 patients referred to hospital from 13 rural clinics; follow-up interviews were conducted with a sub-sample of 57 referred patients. Study II interviewed 97 consecutive outpatients seeking care at Meru District Hospital. Both studies were carried out in a rural area of Meru district in central Kenya. The 602 referred cases represent between 0.3 and 1.8% of all new patients at the respective clinic with a mean of 0.5%, or 8.7 referrals annually per 1000 catchment area population. More than half of the referrals were for treatment only while 13% were for investigation, 63% were considered urgent, and 85% were referred in writing. Of the 57 subsequently interviewed, all except one had complied, and 52 patients, mostly with infections, injuries or obstetric disorders, reported improvement at the time of interview. The second study found that only 19 (20%) of the 97 outpatients had been referred (II in writing and 8 verbally). Rates of formal clinic-to-hospital referral were very low. Reasons included poor access to transport; patient inability to pay user fees, transport outlays, and other expenses; time constraints in emergency situations; and lack of feedback information from hospital to clinic. Verbal referral was common. Further research should focus on the selection of patients for referral, on follow-up of cases referred, on the communication between institutions involved, and on options for the financing of emergency transport to hospital.

A longitudinal health interview survey in rural Kenya: potentials and limitations for local planning

A twelve-month longitudinal household health interview survey in Machakos District (now Makueni District), Kenya, during 1991 covered 390 households randomly selected from 12 village clusters. The survey focused on recent disease symptoms and signs, illness severity, temporary disability and care-seeking behaviour. The total number of reported disease episodes was 9,393, (4.4 per person) with more episodes reported by adult females than by adult males. The disease pattern was dominated by malaria (39.6% of all reported episodes) and respiratory tract diseases (23.1%), followed by gastrointestinal illness (10.7%), joint/muscle disorders (6.4%), injuries (5.4%) and skin conditions (4.8%). Self-medication took place in 39.9% of episodes, while care was sought at hospitals or clinics in 32.1%. This survey generated information useful for local health care planning and management, especially regarding local perception of illness episodes and health care utilization. Respondents developed signs of interview fatigue, however, and the completeness and accuracy of symptom descriptions by the lay interviewers are uncertain. Survey costs were about USD 24,700, one third of which was spent on field work, another third on computerized data processing. Utility in relation to costs is likely to be modest. Improvement of the health information system for local planning and management may be equally or better served by selective improvement of the existing routine reporting system combined with occasional cross-sectional household surveys.

Hospital catchment areas and surgery in Meru district, Kenya

This study of the geographical locations of homesteads of patients undergoing surgery at three hospitals in Meru district, Kenya, showed largely overlapping catchment areas. It also showed catchment areas varying in size with the type of surgical operation under study: Caesarean section, exploratory laparotomy, uterine evacuation, tubal ligation, and normal child delivery. We conclude that catchment areas vary with the disease condition and the health care intervention under study. A precise definition of the catchment area population concept should be developed by ministries of health and then explained to district health teams and health care facility managers for local use in epidemiological surveillance and health care planning.

Injuries in Africa: a review

Injuries--unintentional and intentional--include a wide range of conditions such as road traffic injuries, falls, burns, poisonings, and assaults. Worldwide, unintentional injury is the fifth most common cause of death, responsible for 5.2% of the total mortality. Rates are declining in industrialized countries, for example, in the US from 72/100,000/year around 1900 to 40 in 1982 and 30 in 1988. African injury data are mainly based on hospital records, and few population-based incidence estimates have been made. This review concludes that in sub-Saharan Africa, injuries rank third behind diarrhoea and malaria at 40,000 episodes and 100 deaths per 100,000 population per year. Incidences are higher in males than in females, and the most common cause is fall, followed by road traffic injury, assault, burn and poisoning. Substantial reductions are possible through prevention programmes.

Major and minor surgery at a rural African hospital

Surgical operations performed at Ombo Hospital in Western Kenya from January to December 1989 were studied and annual surgical rates were calculated based on the estimated catchment area population. The total annual rate of major surgery at this church-supported hospital was 207 operations per 100,000 people. This rate is similar to those at other East African hospitals while rates in industrialized countries are 20-35 times higher. The most common major procedures were Caesarean section, laparotomy, hernia repair and salpingectomy. The 1989 rate of minor operations at the hospital was 1286 per 100,000 people with tooth extraction, wound suture, incision and drainage, evacuation of the uterine cavity and closed reduction of fracture as the most frequent procedures. Major operations were performed exclusively by doctors while minor surgery was carried out mainly by clinical officers, nurses and other auxiliary staff.

Effects of new service charges on attendance at rural health facilities in Kenya

Kenyans have long enjoyed free outpatient health care at government facilities while paying for admission and for child delivery. In December 1989 user charges were introduced also for out-patient care at hospitals and health centres. This before-and-after study of one rural hospital, two health centres and two dispensaries in rural Kenya shows major and statistically significant early drops in outpatient attendance at the hospital (28%) and at the health centres (50 and 43%) followed by a slow increase during the following months. There was a modest, not significant, decline also at the dispensaries (14 and 7%) and in demand for services unaffected by the new fees and charges.