Putting Adequate Financial and Human Resources in Healthcare for Effective Universal Health Coverage in Kenya: Lessons and Experiences from China

In recent years, most low and middle-income countries, have adopted different approaches to universal health coverage (UHC), to ensure equity and financial risk protection in accessing essential healthcare services. UHC-related policies and delivery strategies are largely based on existing healthcare systems, a result of gradual development (based on local factors and priorities). Most countries have emphasized on health financing, and human resources for health (HRH) reform policies, based on good practices of several healthcare plans to deliver UHC for their population.

Health financing and labor market frameworks were used, to understand health financing, HRH dynamics, and to analyze key health policies implemented over the past decade in Kenya’s effort to achieve UHC. Through the understanding, policy options are proposed to Kenya; analyzing, and generating lessons from health financing, and HRH reforms experiences in China. Data was collected using mixed methods approach, utilizing both quantitative (documents and literature review), and qualitative (in-depth interviews) data collection techniques.

The problems in Kenya are substantial: high levels of out-of-pocket health expenditure, slow progress in expanding health insurance among informal sector workers, inefficiencies in pulling of health are revenues, inadequate deployed HRH, maldistribution of HRH, and inadequate quality measures in training health worker. The government has identified the critical role of strengthening primary health care and the National Hospital Insurance Fund (NHIF) in Kenya’s move towards UHC. Strengthening primary health care requires; re-defining the role of hospitals, and health insurance schemes, and training, deploying and retaining primary care professionals according to the health needs of the population; concepts not emphasized in Kenya’s healthcare reforms or programs design. Kenya’s top leadership commitment is urgently needed for tougher reforms implementation, and important lessons from China’s extensive health reforms in the past decade are beneficial. Key lessons from China include health insurance expansion through rigorous research, monitoring, and evaluation, substantially increasing government health expenditure, innovative primary healthcare strengthening, designing, and implementing health policy reforms that are responsive to the population, and regional approaches to strengthening HRH.

Investigating the Intrinsic and Extrinsic Drivers of Primate Heterothermy

Seasonal heterothermy—an orchestrated set of extreme physiological responses—is directly responsible for the over-winter survival of many mammalian groups living in seasonal environments. Historically, it was thought that the use of seasonal heterothermy (i.e. daily torpor and hibernation) was restricted to cold-adapted species; it is now known that such thermoregulatory strategies are used by more species than previously appreciated, including many tropical species. The dwarf and mouse lemurs (family Cheirogaleidae) are among the few primates known to use seasonal heterothermy to avoid Madagascar’s harsh and unpredictable environments. These primates provide an ideal study system for investigating a common mechanism of mammalian seasonal heterothermy. The overarching theme of this dissertation is to understand both the intrinsic and extrinsic drivers of heterothermy in three species of the family Cheirogaleidae. By using transcriptome sequencing to characterize gene expression in both captive and natural settings, we identify unique patterns of differential gene expression that are correlated with extreme changes in physiology in two species of dwarf lemurs: C. medius under captive conditions at the Duke Lemur Center and C. crossleyi studied under field conditions in Madagascar. Genes that are differentially expressed appear to be critical for maintaining the health of these animals when they undergo prolonged periods of metabolic depression concurrent with the hibernation phenotype. Further, a comparative analysis of previously studied mammalian heterotherms identifies shared genetic mechanisms underlying the hibernation phenotype across the phylogeny of mammals. Lastly, conducting a diet manipulation study with a captive colony of mouse lemurs (Microcebus murinus) at the Duke Lemur Center, we investigated the degree to which dietary effects influence torpor patterns. We find that tropical primate heterotherms may be exempt from the traditional paradigms governing cold-adapted heterothermy, having evolved different dietary strategies to tolerate circadian changes in body temperature.

Understanding Antenatal Genetics Services in Sri Lanka: Current Landscape of Screening and Diagnostic Services and Contextual Factors Influencing Their Availability and Uptake

Background: Too little information is available on Sri Lanka’s current capacity to provide community genetic services—antenatal genetic services in particular—to understand whether building that capacity could further improve and reduce disparity in maternal and child health. This qualitative research project seeks to gather information on congenital disorders, routine antenatal care, and the current state of antenatal screening testing services within that routine antenatal to assess the feasibility of and the need for scaling up antenatal genetics services in Sri Lanka. Methods: Nineteen key informant (KI) interviews were conducted with stakeholders in antenatal care and genetic services. Seven focus group discussions were held with a total of 56 Public Health Midwives (PHMs), the health workers responsible for antenatal care at the field level. Transcripts for all interviews and FGDs were analyzed for key themes, and themes were categorized to address the specific aims of the project. Results: Antenatal genetic services play a minor role in antenatal care, with screening and diagnostic procedures available in the private sector and paid for out-of-pocket. KIs and PHMs expect that demand for antenatal genetic services will increase as patients’ purchasing power and knowledge grow but note that prohibitive abortion laws limit the ability of patients to act on test results. Genetic services compete for limited financial and human resources in the free public health system, and inadequate information on the prevalence of congenital disorders limits the ability to understand whether funding for services related to those disorders should be increased. A number of alternatives to scaling up antenatal genetic services within the free health system might be better suited to the Sri Lankan structural and social context. Conclusions: Scaling up antenatal genetic services within the public health system is not feasible in the current financial, legal, and human resource context. Yet current availability and utilization patterns contribute to regional and economic disparities, suggesting that stasis will not bring continued improvements in maternal and child health. More information on the burden of congenital disorders is necessary to fully understand if and how antenatal genetic service availability should be increased in Sri Lanka, but even before that information is gathered, examination of policies for patient referral, termination of pregnancy, and government support for individuals with genetic disease are steps that might bring extend improvements and reduce disparity in maternal and child health.