Program Assistant 
Health Challenges and Systems
Overview
Sub-Saharan Africa bears a disproportionate burden of ill-health, and health remains largely under-funded by many governments in the region. In 2010, HIV/AIDS claimed up to 1.2 million lives in Sub-Saharan Africa and a further 22.9 million people, including 2.3 million children, were living with the condition. Pneumonia, diarrheal diseases and malaria and other preventable communicable diseases kill about 4 million children in sub-Saharan Africa each year. The region is also now increasingly threatened by non-communicable diseases (NCDs) such as cancers, cardiovascular diseases, diabetes, and chronic obstructive respiratory disease. Research conducted by the Health Challenges and Systems Program in the previous plan period points to a very high prevalence of HIV (11.5%) in the adult population living in Nairobi’s informal settlements – more than 60% higher than the prevalence for Nairobi (7.0%). In the same population, the adult prevalence of cardiovascular disease conditions (hypertension and diabetes) stands at 17%. These findings point to a dual burden of disease among this impoverished population and confirm what has been observed elsewhere in Africa.
In the past decade, overweight and obesity rates in the region have doubled and, though the prevalence is still low, the upward trend points to a consequential increase in NCDs in the medium and long term. It is estimated that by 2020, NCDs will account for 40% of mortality in sub-Saharan Africa, up from 20% in 2001. These emerging health threats pose new challenges to health systems already strained by cure-centric responses to infectious diseases. APHRC research conducted in Nairobi’s informal settlements shows that cardiovascular disease conditions such as hypertension and diabetes are undiagnosed in the majority (80%) of people with these conditions; those who are diagnosed with the conditions are often untreated; and very few of those under treatment have controlled blood pressure or sugar levels. Poor physical access to health services is compounded by policies and practices that have not kept pace with epidemiological and demographic changes. For instance, outdated treatment guidelines for the management of cardiovascular disease conditions mean that care is not available at primary health care centers, while the health workforce at secondary and tertiary service levels is inadequate and untrained to deal with the large numbers of patients with various NCDs.
There is a dearth of evidence on scalable, cost-effective and sustainable interventions to address these challenges, even as new health threats emerge. For example, climate change will likely have its greatest impacts in developing countries. The region therefore needs to prepare its health systems to respond to extreme weather events while addressing existing environmental challenges such as indoor and outdoor air pollution and water and sanitation scarcity – all major risk factors for morbidity and mortality.
Program Objectives and Strategic Priorities
The program’s main goal is to generate, and synthesize scientific knowledge through research in the following areas with specific priority research topics in each:
a) Epidemiology of infectious and non- communicable diseases and their inter-linkages, with focus on:
- Morbidity and mortality of infectious diseases of the greatest public health importance as determined by Burden of Disease estimates and risk factor studies for non- communicable diseases in different populations.
- Interventions for the control of priority infectious and non- communicable diseases.
b) Critical health systems needs and challenges and the design of effective interventions to address them, with focus on:
- Human resources for health in the face of a dual burden of disease in many sub- Saharan Africa countries.
- Health information systems for the generation of critical evidence for policy and action.
- Integrated service delivery models for the management of chronic conditions.
c) Global environment change and its health impacts with focus on:
- Indoor and outdoor air pollution and its health impacts.
- The role of meteorological factors in health system and population health outcomes.
The program, in meeting its priority objectives and the overarching Center’s strategic objectives, will prioritize research projects that:
- Utilize biomedical techniques where applicable
- Involve partnerships that will enhance the team’s track record in impact evaluation methodologies and climate change research
- Involve more than one country or more than one HDSS site in the INDEPTH Network
Current Projects
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Project Title Indicator Development for Surveillance of Urban Emergencies (IDSUE) Description This is a five year phased research project, implemented in partnership with Concern Worldwide. The project aims to develop and empirically test a set of emergency indicators for an urban slum environment. The project will define indicators of urban emergencies suitable for triggering a humanitarian response. This work will feed into a larger movement in Kenya to identify such indicators as well as fill a critical knowledge and information gap that currently prevents humanitarian actors from effectively and equitably responding to the emergency needs of the urban poor. The first one-year phase of the study was in 2010/2011 in two informal settlements in Nairobi. This was followed by the current phase of the study being implemented in four informal settlements in Nairobi, one informal settlement in Kisumu and one formal settlement in Nairobi. The third phase is expected to begin in November 2012. Project Objectives The project aims to develop and empirically test indicators of urban emergencies suitable for triggering humanitarian response and understand coping mechanisms of the urban poor to emergencies. Specific objectives
Collaborator Concern Worldwide Funder USAID Office of U.S Foreign Disaster Assistance (OFDA-USAID) Project period September 2010-November 2015 Project Team Remare Ettarh, PhD – Project Manager Blessing Mberu, PhD Shukri Mohamed, PharmD, MPH Frederick Wekesah, MSc Catherine Kyobutungi, PhD Thaddaeus Egondi, MSc |
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Project Title INDEPTH Vaccination Project (IVP) Description This is a four year multisite research project being implemented in 6 Health and Demographic Surveillance System (HDSS) within the INDEPTH network, building on previous vaccine studies done in Guinea Bissau, West Africa. The studies have consistently shown that the main childhood interventions with vaccines and micronutrients used by the international health community have the so-called non-specific effects (NSE), i.e. effects which are not explained by the prevention of the targeted infection or deficiency. These effects are often sex-differential. WHO recommends schedules for delivery of vaccines and micronutrients which are often not followed. Many children receive vaccines out-of-sequence; e.g. BCG simultaneously with diphtheria-tetanus-pertussis vaccine (DTP), DTP with measles vaccine (MV), or DTP after MV. Such variations have very different NSE on overall mortality though it has not yet been recognized The project aims to set up systems to monitor and assess the impact of vaccinations and other interventions for both boys and girls in the Nairobi HDSS. The project will also determine the risk factors for delay in uptake of childhood interventions with emphasis on possible differences between boys and girls. The project will also examine the causes of out-of-sequence vaccinations.
Collaborators
Funders DANIDA Project Period Start Date: 01/09/2010 End Date: 31/08/2014 Project Team Martin Kavao Mutua, MSc – Project Manager Peterrock Muriuki, BA Elizabeth Kimani, PhD |
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Project Title Sustainable model for Cardiovascular health by Adjusting Lifestyle and treatment with Economic perspective in settings of Urban Poverty (SCALE UP) Description This is a three year implementation research project that builds on previous observational research, in the same study population of adults, resident in the NUHDSS. The intervention has several components aimed at reducing cardiovascular disease (CVD) risk within a continuum of care framework. These components include mass screening of all adults older than 35 years, CVD risk assessment, individual counseling for those with low risk, referral for those with moderate and high risk, and care and treatment at a specially established clinic, with incentives to enhance adherence to the care regime. Project Objectives The project aims to develop, implement and evaluate a cost-effective and affordable community-based model of interventions for primordial and primary prevention and management of cardiovascular risk factors suitable for scaling up in slum settings in sub-Saharan Africa. Specific objectives
Collaborators
Funder AMC Foundation Project Period Start date: 15/07/2011 End date: 15/07/2014 Project Team Catherine Kyobutungi, PhD – Project Manager Samuel Oti, MSc - PhD candidate Steven van de Vijver , MPH - PhD candidate Moses Mwithiga , BA |
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Project Title Maternal, Infant and Young Child Nutrition Project (MIYCN) Description The project is an intervention that involves personalized home-based counselling of pregnant women and mothers of infants on maternal nutrition and optimal infant and young child feeding practices. The intervention will be delivered by Community Health Workers (CHWs), who are already part of the existing primary health care system. Training of community health workers is based on adapted training materials from the WHO. Counselling sessions are structured taking cognizance of the stages of change framework, and understanding that behaviour change occurs in different stages over time. Counselling is initiated before the third pregnancy trimester on maternal nutrition during pregnancy and lactation, optimal breastfeeding practices including breast positioning and attachment, immediate initiation of breastfeeding after birth, exclusive breastfeeding for six months, frequency and duration of breastfeeding, expressing breast milk and complementary feeding: appropriate timing, appropriate complementary foods, weaning time, (safe, nutritious, affordable, and locally available; appropriate feeding frequency and quantity, and appropriate feeding practices including hygiene and responsive feeding behaviours). Project objective To determine the effectiveness of personalized home-based nutritional counselling on maternal, and infant feeding practices and consequently morbidity and nutritional outcomes in two Nairobi slums. Specific objectives
Collaborators
Funder The Wellcome Trust, UK through a Research Training Fellowship Project period Start Date: March 2012 End Date: February 2015 Project Team Elizabeth Kimani, PhD – Project Manager and Fellow Alex Ezeh, PhD - Sponsor Catherine Kyobutungi, PhD Frederick Wekesah, MSc Milka Wanjohi Njeri, BSc Peterrock Muriuki, BA |
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Project Title Triple Negative Breast Cancer in Kenya (TNBC) Description Triple negative breast cancer (TNBC) is an aggressive form of breast carcinoma with a poor prognosis. This is a type of cancer that test negative to the estrogen, progesterone and Her2 receptors. Hence these cancers do not respond to the conventional receptor targeted treatments. To date in Kenya, there has been little progress in the identification and treatment of breast cancer sub-types, and TNBC in particular, since most health care facilities in the region lack technical resources and expertise for basic Immunohistochemistry (IHC) and breast cancer sub-classification. Thus, treatment of breast cancer is often based on clinical staging and suboptimal histology reports. Hence, there is dire need for validated, receptor-based sub-classification of breast cancers in Kenyan women, and specifically the identification of high risk TNBC. The study intends to determine the prevalence of TNBC and study the associated tumor clinico-pathologic characteristics and patient socio-demographics amongst three distinct ethnic groups (Bantu, Nilotes & Cushites) in Kenya. The short term impact of the research is the characterization of all breast cancer subtypes, with a special focus on TNBC, in the Kenyan population and to contribute to capacity-building and technical expertise for the diagnosis and management of breast cancer in the country. Project Objectives:
Collaborators
Funder GlaxoSmithKline – Ethnic Research Initiative Project Period Start Date: March 2012 End Date: February 2014 Project Team Catherine Kyobutungi, PhD – Co-PI Shukri Mohamed, PharmD, MPH Thaddaeus Egondi, MSc Nelson Mbaya, BSc |
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Project Title Partnership for Maternal, Newborn and Child Health Project (PAMANECH) Description The rapid urbanization in Kenya (with an annual rate of 4%) has been characterized by the mushrooming of urban informal settlements in the last two decades. The public healthcare systems have not been able to keep up with this rapid growth and in turn they have not been able to cater for the health needs of those in the informal settlements. Private health facilities have therefore come up to deliver health services making the ratio of public to private health facilities serving slums residents 1:100. PAMANECH is a project being implemented in two slums in Nairobi namely Viwandani and Korogocho. The main objective of PAMANECH is to assess the impact of strengthening public-private partnership for the delivery of health care on the health of mothers, newborns and young children. The project will strengthen the infrastructure of selected Private Not for Profit health facilities that already operate in the two slums, provide training opportunities for staff working at these facilities and provide supportive supervision from the local district health authorities. By doing this, PAMANECH aims to increase the number of health facilities offering high quality and lifesaving health care to the slum population who will offer both preventive and curative service at convenient times for the slums residents including weekends and late night when most mothers and caregivers return from their days jobs. Support services will include a network of community health workers to identify and refer mothers and children in need of health care and a night-escort service run by youth groups to accompany any woman or family that need medical attention in the middle of the night or when it is not safe to access health services. Study Objectives These are implied in the project’s learning questions, which are:
The overarching learning question is: “How can health care services in informal slum settlements be strengthened through public-private partnerships for service provision?” Collaborators
Funder Comic Relief Project period Start Date: July 2012 End Date: December 2015 Project Team Catherine Kyobutungi, PhD – PI Remare Ettarh, PhD Nicholas Ngomi, MSc Eva Kamande, MSc Thaddaeus Egondi, Msc |
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Project Title Epidemiology, Ecology and Socio-Economics of Disease Emergence in Nairobi (Urban Zoonoses Project) Description A combination of growth and migration is resulting in substantial increases in the population of Urban and Peri-Urban (UPU) zones in Africa, rising from 35% of the total population in 2007 to a projected 51% by 2030. Urbanized environments in Africa are melting pots of activity and interaction: livestock live alongside people; human and livestock waste is poorly disposed of near food production areas; formal and informal trading takes place in internal and externally connected networks. This degree of mixing and contact creates ecological niches with opportunities for pathogen transmission, and several influential reports have linked urbanization to the risk of emerging infectious diseases. However, little is known on the impact of urbanization on the transmission of microbial floral especially pathogens. Approximately 60% of human pathogens are zoonotic, and approximately 80% of novel pathogens have zoonotic origins. It is also thought that the processes leading to the emergence of novel pathogens are similar to those resulting in exposure to and spread of known zoonotic pathogens. Our understanding of the mechanisms and processes underlying the emergence of novel pathogens should benefit from investigation of pathogens that we already know about. This will go a long way in improving our ability to predict the emergence and spread of new infectious diseases hence provide an opportunity to understand the biology and ecology of existing pathogens. The study will use an interdisciplinary approach to study E. coli as an exemplar microbe for this purpose because it is zoonotic, exists in many hosts, in most environments, on food and in milk and has pathogen and non-pathogen forms. Project Objectives The overall objective of this project is to understand the mechanisms that may lead to the introduction of pathogens into urban environments, and the emergence of those pathogens in the human population. APHRC will contribute to the conduct of two sub-studies:-
Collaborators
Funder MRC-Environmental and Social Ecology of Human Infectious Diseases Project period Start Date: January 2012 End Date: December 2016 Project Team Catherine Kyobutungi, PhD – Co PI Djesika Amendah, PhD – Project Manager Nicholas Ngomi, MSc |
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Project Title Indoor and Outdoor Air Pollution and Their Health Impacts, in Poor Urban Settings in Nairobi Description Air pollution (both outdoor and indoor) is a critical public health challenge especially in the developing world where legislation on emissions control is either weak or non-existent. In these countries, majority of households rely on fuels for cooking and heating that have been classified as high source of pollution. Studies have documented the negative effects of both outdoor and indoor air pollution on health; however, there have been very few such studies in Africa. The study shall use a mixed methods approach where a qualitative study will be conducted to look at the perceptions and attitudes of residents regarding air pollution and a quantitative study that will measure levels of both indoor and outdoor air pollution to establish the levels of air pollution and their association with health outcomes. The project is being implemented by two APHRC researchers enrolled in a sandwich PhD program at Umea University. Project Objectives
Collaborators
Funders APHRC Umea University Project period Start Date: March 2012 End Date: February 2014 Project Team Thaddaeus Egondi, MSc (PhD Candidate) Kanyiva Muindi, MPH (PhD Candidate) Djesika Amendah (TE supervisor) Elizabeth Kimani (KM supervisor) |
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Project Title Verbal Autopsy (VA) Studies for Cause of Death Ascertainment in the Nairobi Urban Health and Demographic Surveillance System Description Developing countries generally lack complete vital registration systems that can produce cause-of-death information for health planning in their populations. As an alternative, Verbal Autopsy (VA) –the process of interviewing family members or caregivers on the circumstances leading to death, is often used by Demographic Surveillance Systems (DSS) to generate COD data. The aim of the VA project is to collect, analyze and report mortality data in order to describe the burden of disease profile in the informal settlements of Nairobi, Kenya. Collaborators INDEPTH Network Funder DSS contribution Project period Start Date: Jan 2003 End Date: Ongoing as long as NUHDSS is operational Project Team Samuel Oti, MSc – Project Manager |
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Project Title WHO- Technical Assistance for Accountability for Health Framework in Africa Description Accountability is now very important in the health care sector. The Commission on Information and Accountability for Women's and Children's Health set up by the UN Secretary General, HE Ban Ki-Moon concluded that there is need to focus on improving information for better results, tracking of resources and stronger oversight for results and resources. Key challenges identified by the Commission included lack of capacity for collecting and analysing data and tracking resources allocated to health, particularly to Maternal Newborn and Child Health (MNCH), weak civil registration systems, duplication of efforts among others. The commission came up with 10 recommendations for action:
Through WHO, APHRC is providing technical assistance to selected countries to implement and assess progress in achieving the recommendations for improving Women’s and Children’s health. This will be done through several activities including:-
Collaborators
Funder WHO Project period Start Date: May 2012 End Date: September 2013 Project Team Ziraba Abdhalah, MPH – Responsible for Results accountability Djesika Amendah, PhD – Responsible for Resources accountability |
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Project Title Support for Health System Strengthening to Rwanda Description Rwanda is one of the few countries in Africa to implement universal health care coverage. To sustain and strengthen this policy and other initiatives, the government of Rwanda is interested in building its capacity to implement, monitor and evaluate programs, specifically in the area of health economics and health policy analysis. Project objectives: The objective of the project is to develop the following products:
Funder The Rockefeller Foundation Project period Start Date: Nov 2011 End Date: Dec 2012 Project Team Djesika Amendah, PhD – Project Manager |
