A systems approach to examining health sector responses to cholera epidemics in Kenya
Lead Research Organisation:
Strathmore University
Department Name: Institute of Healthcare Management, SBS
Abstract
Simple Summary
Kenya has experienced an increased disease burden due to cholera outbreaks characterized by continuous transmission in the refugee camp settings of Garissa and Turkana, and sporadic transmission in cities such as Nairobi and Mombasa. However, while inquiry has been made regarding how the health sector has responded to and how populations have been impacted by epidemics such as cholera, not enough attention has been paid to causal relationships between the unique components of the health systems leading to an inadequate understanding of how the building blocks of the health systems interact in disease surveillance and epidemic response. Consequently, this research effort focuses on examining the health sector responses to these epidemics, developing a systems-theory-based description of the said responses, and based on the results, provide recommendations that may help break the epidemic's continuous and cyclical nature.
The study will be conducted in Turkana and Garissa in Kenya, as well as in Nairobi. These are counties that have diverse levels of health system sophistication and recent experiences of cholera epidemics. Moreover, the study draws on several systems analytic frameworks to determine the actors and their decisions, as well as their inter-relationships, linkages and dependencies. Thus, the study appropriates systems-oriented research techniques and applies them in a novel fashion to the assessment of health service delivery. The findings of this study are expected to guide interventions aimed at improving disease surveillance and epidemic response. The study will also act as a primer for the research community by assessing the utility of systems-thinking approaches in such settings, and subsequently opening a related research agenda.
Kenya has experienced an increased disease burden due to cholera outbreaks characterized by continuous transmission in the refugee camp settings of Garissa and Turkana, and sporadic transmission in cities such as Nairobi and Mombasa. However, while inquiry has been made regarding how the health sector has responded to and how populations have been impacted by epidemics such as cholera, not enough attention has been paid to causal relationships between the unique components of the health systems leading to an inadequate understanding of how the building blocks of the health systems interact in disease surveillance and epidemic response. Consequently, this research effort focuses on examining the health sector responses to these epidemics, developing a systems-theory-based description of the said responses, and based on the results, provide recommendations that may help break the epidemic's continuous and cyclical nature.
The study will be conducted in Turkana and Garissa in Kenya, as well as in Nairobi. These are counties that have diverse levels of health system sophistication and recent experiences of cholera epidemics. Moreover, the study draws on several systems analytic frameworks to determine the actors and their decisions, as well as their inter-relationships, linkages and dependencies. Thus, the study appropriates systems-oriented research techniques and applies them in a novel fashion to the assessment of health service delivery. The findings of this study are expected to guide interventions aimed at improving disease surveillance and epidemic response. The study will also act as a primer for the research community by assessing the utility of systems-thinking approaches in such settings, and subsequently opening a related research agenda.
Technical Summary
Technical Summary
Kenya has experienced an increased disease burden due to cholera outbreaks characterized by continuous transmission in the refugee camp settings of Garissa and Turkana, and sporadic transmission in cities such as Nairobi and Mombasa. However, while inquiry has been made regarding how the health sector has responded to and how populations have been impacted by epidemics such as cholera, not enough attention has been paid to causal relationships between the unique components of the health systems leading to an inadequate understanding of how the building blocks of the health systems interact in disease surveillance and epidemic response. Consequently, this research effort focuses on examining the health sector responses to these epidemics, developing a systems-theory-based description of the said responses, and based on the results, provide recommendations that may help break the epidemic's continuous and cyclical nature.
The study will be conducted in Turkana and Garissa in Kenya, as well as in Nairobi. These are counties that have diverse levels of health system sophistication and recent experiences of cholera epidemics. Moreover, the study draws on several systems analytic frameworks - specifically Rasmussen's Risk Management Framework and its attendant AcciMap, the Analytic Hierarchy Process tool, and Cognitive Work Analysis - to determine the actors and their decisions, as well as their inter-relationships, linkages and dependencies. Thus, the study appropriates systems-oriented research techniques and applies them in a novel fashion to the assessment of health service delivery. The findings of this study are expected to guide interventions aimed at improving disease surveillance and epidemic response, and to act as a primer for the research community by assessing the utility of systems-thinking approaches in such settings.
Kenya has experienced an increased disease burden due to cholera outbreaks characterized by continuous transmission in the refugee camp settings of Garissa and Turkana, and sporadic transmission in cities such as Nairobi and Mombasa. However, while inquiry has been made regarding how the health sector has responded to and how populations have been impacted by epidemics such as cholera, not enough attention has been paid to causal relationships between the unique components of the health systems leading to an inadequate understanding of how the building blocks of the health systems interact in disease surveillance and epidemic response. Consequently, this research effort focuses on examining the health sector responses to these epidemics, developing a systems-theory-based description of the said responses, and based on the results, provide recommendations that may help break the epidemic's continuous and cyclical nature.
The study will be conducted in Turkana and Garissa in Kenya, as well as in Nairobi. These are counties that have diverse levels of health system sophistication and recent experiences of cholera epidemics. Moreover, the study draws on several systems analytic frameworks - specifically Rasmussen's Risk Management Framework and its attendant AcciMap, the Analytic Hierarchy Process tool, and Cognitive Work Analysis - to determine the actors and their decisions, as well as their inter-relationships, linkages and dependencies. Thus, the study appropriates systems-oriented research techniques and applies them in a novel fashion to the assessment of health service delivery. The findings of this study are expected to guide interventions aimed at improving disease surveillance and epidemic response, and to act as a primer for the research community by assessing the utility of systems-thinking approaches in such settings.
Planned Impact
Health crises and emergencies are postulated to have a profound effect on the current and future state of health systems in developing countries such as Kenya, and their achievement in Sustainable Development Goal 3. Generating context specific evidence on how the health sector prepares and responds to such health emergencies will be critical in exploring pathways to strengthen the resilience of health systems in the delivery of health services.
In addition, the evidence generated from this study will be used to advocate for the use of a health system approach in preparing for and responding to health emergencies, especially those with humanitarian consequences. For such to be possible, an understanding of the synergies between the health systems building blocks is important. Such understanding can be possible when an appropriate systems approach such as the one we propose in this study is used.
For the research community, the study intends to provoke the development of a research agenda around health emergencies using systems analytic techniques. The research effort will for example present several contributory factors and suggest their placement and relationships within and across levels. It will also present a preliminary set of codes for categorizing the contributory factors by type, actor, and level as well as the relationships between them
In addition, the evidence generated from this study will be used to advocate for the use of a health system approach in preparing for and responding to health emergencies, especially those with humanitarian consequences. For such to be possible, an understanding of the synergies between the health systems building blocks is important. Such understanding can be possible when an appropriate systems approach such as the one we propose in this study is used.
For the research community, the study intends to provoke the development of a research agenda around health emergencies using systems analytic techniques. The research effort will for example present several contributory factors and suggest their placement and relationships within and across levels. It will also present a preliminary set of codes for categorizing the contributory factors by type, actor, and level as well as the relationships between them
| Description | Partnership with County Governments of Garissa and Turkana |
| Organisation | Garissa County Government |
| Country | Kenya |
| Sector | Public |
| PI Contribution | Through the partnership with the two counties we are able to access records related to cholera outbreaks. |
| Collaborator Contribution | Through the county governments we are able to -Access the health facilities in the refugee camps -Get volunteers to help with data collection who have knowledge on the humanitarian situation and conversant with the areas that normally have cholera outbreaks - Have top government officials participate in our learning tour. |
| Impact | Through our collaboration with the counties; Access the health facilities in the refugee camps -Get volunteers to help with data collection who have knowledge on the humanitarian situation and conversant with the areas that normally have cholera outbreaks - Have top government officials participate in our learning tour. The collaboration is multidisciplinary as we have the following departments working with us -Ministry of education -Ministry of planning and development -Ministry of health -Ministry of water and sanitation |
| Start Year | 2020 |
| Description | Partnership with County Governments of Garissa and Turkana |
| Organisation | Turkana County Government |
| Country | Kenya |
| Sector | Public |
| PI Contribution | Through the partnership with the two counties we are able to access records related to cholera outbreaks. |
| Collaborator Contribution | Through the county governments we are able to -Access the health facilities in the refugee camps -Get volunteers to help with data collection who have knowledge on the humanitarian situation and conversant with the areas that normally have cholera outbreaks - Have top government officials participate in our learning tour. |
| Impact | Through our collaboration with the counties; Access the health facilities in the refugee camps -Get volunteers to help with data collection who have knowledge on the humanitarian situation and conversant with the areas that normally have cholera outbreaks - Have top government officials participate in our learning tour. The collaboration is multidisciplinary as we have the following departments working with us -Ministry of education -Ministry of planning and development -Ministry of health -Ministry of water and sanitation |
| Start Year | 2020 |
| Description | Learning meeting with stakeholders in Turkana and Garissa Counties |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Policymakers/politicians |
| Results and Impact | The meetings in both counties was carried out to brief the necessary stakeholders on the project. Part of the meeting included introducing the project team from both Strathmore University and Kenya Red Cross, give a brief on what the project is about and who the funders are, the project duration, and proposed areas of collaboration with the two counties. Brief on Garissa and Turkana County Garissa County is one of the three counties in the North-Eastern region of Kenya. It covers an area of 44,174.1 Km2 and has a total population of 842,353 people. There are six unclassified urban centers, namely: Balambala, Bura East, Dadaab, Modogashe, Nanighi and Hulugho. The county is also host to three refugee camps in Dadaab that is; Hagadera, Dagahaley and IFO camp. In 2019 through voluntary repatriation, the former Kambioos and IFO2 refugee camps were shut down and handed back to both the County and National governments. Turkana County is located in the northwest part of Kenya, and it covers 77,000 sq. Km with a population of 1million people constituting 2.2% of the national population. Lodwar town is the capital of the county and has the largest urban population taking 6% of the county's population, Kakuma 4% which also houses the refugee camp, and Lokichogio 2%. Objectives of the field visits The face to face meetings were conducted with the County Executive Committee for health (CEC), Director of health for both counties, head of monitoring and evaluation, head of disease surveillance, Red Cross county coordinators, and health workers working in the various hospitals in the refugee camps. The aim of the visits was to help the research team get an in-depth understanding of the cholera response in both counties from 2014 to date. The meetings were also project inception meetings meant to brief the county teams about the project, proposed timelines and the role of the counties in ensuring the project is a success both at their level and national level. Reasons for cholera outbreaks in both Counties The teams in both the counties identified the areas below as the key drivers for cholera outbreaks; - Lack of adequate latrine coverage in the camps which leads families to help themselves in the open fields. - Sociocultural factors in the use of the latrines encourage the spread of cholera, such as the use of the latrines by males and females. - Because the area has sandy soil, the latrines can only be dug three meters deep thus when it rains the waste matter from latrines that are full leach out into the surrounding environment. - Lack of adequate enforcement in the management of cholera by partners in the camps such as WASH, food handling, among others. - The porous border with Somalia that allows movement of people from Somalia to Kenya, this movement enhances the spread of cholera in the host community and camps and also inter-camp movement encourages the spread. - MOH many times has been overwhelmed in the control of the outbreaks due to overcrowding in the camps and insufficient water at the household level. The households get 20 liters of water per capita per day which is not enough for the households which have between 25-35 individuals. - Allocation of residential compounds is very small compared to the household numbers How the counties and partners are working to contain future outbreaks 1. All case management is done as per MOH and WHO guidelines with CTU's used for admission of patients whose culture samples are positive. 2. Active contact tracing and case finding are done by community health workers when there is an outbreak. During this period the different agencies also carry out an analysis to find out what caused the outbreak through intensive case finding through outreach programs and household visits, water treatment kits are issued in the affected areas 3. Emphasis is given to water and sanitation that is managed by CARE international who are the first responders when there is an outbreak in the camps. Water quantity and quality are assessed during this time. 4. Enhanced hygiene promotion at the community level is carried out when there is an outbreak this includes health education and promotion in schools since they usually are the epicenter of the outbreak due to poor sanitation. 5. Different organizations working in the camps come together to slow the spread. Key achievements to date - There has been no readmission of cholera cases due to active case finding - Minimal mortality rates in the affected camps - There is increased community involvement, this includes the churches, mosques and community leaders giving a voice in the prevention and management of outbreaks. - Since the COVID-19 outbreak, there has been no reported case of cholera in both counties due to the increased sensitization on hygiene practices such as hand washing. Reporting structure for a disease outbreak in the refugee camp. Outcomes of the meeting - The county to help in coordinating sensitization meetings with employees especially those in the camps in preparation for data collection - The director and other identified staff to work with the project team in developing policy briefs when the time comes - The counties to be champions for the proposed policies and ensure they are circulated throughout the county and at national level - The county to avail personnel near the camps to help with data collection so as to ensure community participation. |
| Year(s) Of Engagement Activity | 2020 |
| Description | Research methods training |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Postgraduate students |
| Results and Impact | The training workshops conducted were mainly to provide a platform for researchers and students to gain knowledge in understanding, analysing and describing quantitative and qualitative data. The activity took place at the University that is strathmore University and Severine cottages through a hybrid method that is both online and physical participation. The initial trainings covered qualitative and quantitative analysis with the last training covering the development of the AcciMap. The trainings took place between the months of August and October 2021. The research paradigms training mainly targeted staff working in the project both in IHM and ICHA/Red Cross. The main aim of the objectives of the training included: 1. The participants to gain knowledge on research paradigms, research designs, the selection of a research approach, and Literature Reviews. 2. The participants o gain knowledge on Systems Analytic Approaches and analysis of qualitative data 3. The participants to gain knowledge on the survey design and analysing quantitative data 4. The participants to gain knowledge on Moderation and Mediation analysis The training program was as follows: Qualitative • Part 1: Reviewing the basics - research paradigms, research designs, the selection of a research approach; Part 2 - an overview of approaches to qualitative inquiry; Part 3 - Literature Reviews • Systems Analytic Approaches • Analyzing Qualitative Data Quantitative methods • Part 1- the survey design; Part 2 - analyzing quantitative data • Moderation and Mediation A total of 25 participants participated in the trainings which proved very beneficial especially for the students who were yet to begin data analysis and those who were in the process of developing their proposals. The AcciMap training was carried out to the staff at the Institute of Healthcare management to help in the process of developing the map based on the data collected |
| Year(s) Of Engagement Activity | 2021 |