Abstractobjective To determine and compare, among three models of care, compliance with scheduled clinic appointments and adherence to antihypertensive medication of patients in an informal settlement of Kibera, Kenya.methods Routinely collected patient data were used from three health facilities, six walkway clinics and one weekend/church clinic. Patients were eligible if they had received hypertension care for more than 6 months. Compliance with clinic appointments and self-reported adherence to medication were determined from clinic records and compared using the chi-square test. Univariate and multivariate logistic regression models estimated the odds of overall adherence to medication.results A total of 785 patients received hypertension treatment eligible for analysis, of whom twothirds were women. Between them, there were 5879 clinic visits with an overall compliance with appointments of 63%. Compliance was high in the health facilities and walkway clinics, but men were more likely to attend the weekend/church clinics. Self-reported adherence to medication by those complying with scheduled clinic visits was 94%. Patients in the walkway clinics were two times more likely to adhere to antihypertensive medication than patients at the health facility (OR 1.97, 95% CI 1.25-3.10).conclusion Walkway clinics outperformed health facilities and weekend clinics. The use of multiple sites for the management of hypertensive patients led to good compliance with scheduled clinic visits and very good self-reported adherence to medication in a low-resource setting.keywords hypertension, models of care, walkway clinics, weekend clinics, medical management, operational research

As human immunodeficiency virus (HIV) treatment programs expand in Africa, delivery systems must be strengthened to support patient retention. Clinic characteristics may affect retention, but a relationship between clinic flow and attrition is not established. This project characterized HIV patient experience and flow in an urban Kenyan clinic to understand how these may affect retention. We used Toyota's lean manufacturing principles to guide data collection and analysis. Clinic flow was evaluated using value stream mapping and time and motion techniques. Clinic register data were analyzed. Two focus group discussions were held to characterize HIV patient experience. Results were shared with clinic staff. Wait times in the clinic were highly variable. We identified four main barriers to patient flow: inconsistent patient arrivals, inconsistent staffing, filing system defects, and serving patients out of order. Focus group participants explained how clinic operations affected their ability to engage in care. Clinic staff were eager to discuss the problems identified and identified numerous low-cost potential solutions. Lean manufacturing methodologies can guide efficiency interventions in low-resource healthcare settings. Using lean techniques, we identified bottlenecks to clinic flow and low-cost solutions to improve wait times. Improving flow may result in increased patient satisfaction and retention.

With continued undernutrition and escalating overnutrition, urbanization, and resource-strapped health systems, nations-particularly those in the low-and middle-income brackets-are facing the harsh reality of a growing double burden of communicable and noncommunicable diseases (NCD) [1,2]. The dearth of a skilled health workforce is a principal concern when it comes to tackling these challenges, as health care systems and health care training programs are set up to respond to acute care needs and struggle to deliver prevention and care for chronic conditions [3,4]. Although efforts to ramp up education and training on NCD among physicians, pharmacists, nurses, and other skilled health workers is urgently needed and must be prioritized, empowered Community Health Workers (CHW) present a secret weapon to combating NCD.CHW are responsible for certain aspects of health care delivery within the community in which they live, and they apply their deep understanding of local population needs in their roles as service extension workers and agents of social change [5][6][7][8][9]. Although we use the term CHW in this paper, they receive many different titles across countries and programs [7,[10][11][12]. CHW are not unskilled labor, although they generally have no formal professional or paraprofessional training and are thus not recognized as part of the formal health system in most countries [13]. Given the reach of CHW to otherwise underserved populations across rural and urban settings worldwide, we explore their potential to address NCD burdens across countries in this paper, and we suggest that their role in the formal health system warrants renewed consideration.

BackgroundWe examine the uptake of HIV Testing and Counselling (HTC) and linkage into care over one year of providing HTC through community and health facility testing modalities among people living in Kibera informal urban settlement in Nairobi Kenya.MethodsWe analyzed program data on health facility-based HIV testing and counselling and community- based testing and counselling approaches for the period starting October 2013 to September 2014. Univariate and bivariate analysis methods were used to compare the two approaches with regard to uptake of HTC and subsequent linkage to care. The exact Confidence Intervals (CI) to the proportions were approximated using simple normal approximation to binomial distribution method.ResultsMajority of the 18,591 clients were tested through health facility-based testing approaches 72.5 % (n = 13485) vs those tested through community-based testing comprised 27.5 % (n = 5106). More clients tested at health facilities were reached through Provider Initiated Testing and Counselling PITC 81.7 % (n = 11015) while 18.3 % were reached through Voluntary Counselling and Testing (VCT)/Client Initiated Testing and Counselling (CITC) services. All clients who tested positive during health facility-based testing were successfully linked to care either at the project sites or sites of client choice while not all who tested positive during community based testing were linked to care. The HIV prevalence among all those who were tested for HIV in the program was 5.2 % (n = 52, 95 % CI: 3.9 %–6.8 %). Key study limitation included use of aggregate data to report uptake of HTC through the two testing approaches and not being able to estimate the population in the catchment area likely to test for HIV.ConclusionHealth facility-based HTC approach achieved more clients tested for HIV, and this method also resulted in identifying greater numbers of people who were HIV positive in Kibera slum within one year period of testing for HIV compared to community-based HTC approach. Linking HIV positive clients to care proved much easier during health facility- based HTC compared to community- based HTC.

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