Triangle  Global  Health  Case  Competition   Cardiovascular  Disease  in  Kenya   MARCH  26  –  31,  2012   A  collaboration  of:  

       

With  generous  support  from:  

       

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PACKET OVERVIEW This packet contains the 2012 Triangle Global Health Case Competition problem statement, instructions for all student competitors, and general background information that will help you in your case presentation. A resource list and the judging rubric are also included. Use the information presented in this packet: • To obtain a broad understanding of the dynamic disease burden in Kenya and the role of

current health systems and partnerships to address these challenges; • To stimulate group thinking of intervention strategies; and • To use as a starting point for your team’s research and presentation planning process. JUDGING RUBRIC The judging panel will evaluate the proposals, looking for the most sustainable, financially justifiable, and acceptable course of action. Your proposal recommendations should be specific and executable. Be prepared to answer questions that may force you to think on your feet. In evaluating proposals, judges will consider the following:

• Creativity and innovation • Rationale and justification for solution(s) • Delivery of proposed solution(s) • Clarity and organization

Category Points Possible

Creativity and innovation of proposal ● Thorough analysis of the problem ● Definition of specific problem(s) for analysis ● Introduction of innovative ideas and/or technologies

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Rationale and justification ● Impact of proposed solution(s) on achieving goal ● Economic, time and personnel feasibility and management ● Sustainability of solution(s)

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Delivery of proposed solution(s) ● Analysis of challenges and weaknesses ● Practicality of solution(s) ● Consideration of multiple perspectives & populations

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Clarity and organization ● Clarity and organization in the presentation ● Command of questions and feedback

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100

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PROBLEM STATEMENT: REQUEST FOR APPLICATIONS FROM THE GATES FOUNDATION The Bill & Melinda Gates Foundation is requesting applications to expand current public health programs in place, such as those focused on HIV/AIDS, maternal and child health, and reproductive health, to address cardiovascular disease (CVD). Specifically, you are asked to identify and address at least one CVD endpoint (e.g. ischemic heart disease, stroke, heart failure, cardiomyopathy, valvular heart disease) and/or CVD risk factor (e.g. diabetes, hypertension, dyslipidemia, obesity, tobacco use) in your strategy, and you are strongly encouraged to address some or all of the following elements in your strategy: (1) use of innovative technologies, (2) issues of access, (3) gender challenges, and (4) the role of the health worker. The Gates Foundation is dedicated to saving lives and hopes that recipients of the award will reduce the rapidly expanding burden of cardiovascular disease in Kenya. INSTRUCTIONS Working together with your team of 4-6 people, create a 12-minute in-person, oral presentation (or pitch) with supporting PowerPoint slides to respond to this Request for Applications from the Gates Foundation. Your team will play the role of representatives from an organization – for-profit, non-profit, OR academic institution. You can create your own or use an existing agency that works in the region. Grants will be made for up to $15 million (USD) over the course of four years. The audience of your pitch will be a special commission of experts from the field convened by leadership of the Gates Foundation. The presentation can be made by one or more members of the group, but all members must attend and be able to respond to questions. There will be 8 minutes of Q&A following your presentation. Please also include two supplementary slides: (1) references and (2) a short (one-sentence) description of each group member’s contributions to the overall project (you do not need to go over these slides during your presentation).

All PowerPoint slides are due on Saturday, March 31st, 2012 at 8:30am via the provided jump drive. Late entries will NOT be accepted.

Each team must print out 4 copies of their slides for members of the judging panel. NO PRINTING is available at the site of the competition. Please conserve paper by printing on both sides and placing 4 slides per page.

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KENYA AT A GLANCE The Republic of Kenya is located in Eastern Sub-Saharan Africa and bordered by Tanzania to the south, Uganda and South Sudan in the West, Ethiopia in the North, and by the Indian Ocean and Somalia in the East. Kenya struggles with high levels of poverty, particularly in the Eastern and Coastal regions. Progress on the Millennium Development Goals (MDGs) has been stagnated by a combination of global economic downturn, external region instability, and internal post-election turbulence in 2007-2008.

Demography ● Population: 40,513,000 (UNICEF, 2010)

○ Kikuyu 22%, Luhya 14%, Luo 13%, Kalenjin 12%, Kamba 11%, Kisii 6%, Meru 6%, other African 15%, non-African 1% (CIA, 2012)

○ % of population living in urban areas: 22.5% (UNDP, 2012) ○ Crude Birth Rate (per 1,000): 31.9 (CIA, 2012) ○ Crude Death Rate (per 1,000): 7.3 (CIA, 2012)

● Major Languages: Kiswahlili & English (CIA, 2012) ● Major Religions: Protestant 45%, Roman Catholic 33%, Muslim 10%, indigenous 10%,

other 2% (CIA, 2012) Economy

● GDP per capita (2010, US$), PPP: 1,477 (WHO, 2010) ● Population Living Below $1 per day (2005, PPP): 19.7 (WHO, 2005) ● Unemployment Rate %: 40 (est. 2008) (CIA, 2012) ● United Nations Human Development Index: 0.509, Rank 143/187 (WHO, 2008) ● Total Expenditure on Health as % of GDP: 4.3 (WHO, 2008)

Health

● Life Expectancy (2010): 57 (UNICEF, 2010) ● Infant Mortality (per 1,000): 55 (UNICEF, 2010) ● Under-5 Mortality (per 1,000): 82 (Rajaratnam, 2010) ● Measles immunization of children (1 year and younger, 2009): 94 (WHO, 2011a) ● Maternal Mortality Rate (per 100,000 live births): 413 (Hogan, 2010) ● % of births occurring in rural areas: 81 (WHO, 2003) ● % of women receiving antenatal care (at least once) : 92 (UNICEF, 2010)

○ % of pregnant women who received antenatal care services counseled and tested for HIV: 5

○ % of pregnant women who received antenatal care services counseled for HIV but not tested: 29

○ % of pregnant women who received antenatal care service were tested for HIV only: 9 (WHO, 2007)

● % of women with skilled birth attendant at delivery: 44 (UNICEF, 2010) Public Health and Country Infrastructure

● % of population using improved drinking water sources, total: 59 (WHO, 2008) ● % of population using improved sanitation facilities, total: 31 (WHO, 2008) ● Nursing and midwifery personnel density per 100,000 persons, 2002: 11.8 (WHO, 2002)

Figure 1. Map of Kenya (CIA, 2012)

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Education ● % of GDP Expenditure on Education: 7% (UNDP, 2011) ● Total adult literacy rate (%): 87 (UNICEF, 2010) ● Primary school net enrollment ratio (%): 83 (UNICEF, 2010)

Additional Population Characteristics

● Mobile Network Coverage: 83% (L. Brannstrom, 2012) ● Mobile phone Subscribers per 100 persons: 42.1 (L. Brannstrom, 2012) ● Internet Subscribers per 100 persons: 1.1 (L. Brannstrom, 2012) ● Estimated internet users per 100 persons: 8.7 (L. Brannstrom, 2012)

HEALTH CHALLENGES IN KENYA HIV/AIDS in Kenya

Like many Southeastern African nations, Kenya remains stricken by the global HIV/AIDS pandemic. Kenya’s sparse vital registry database makes it difficult to estimate the real extent of HIV/AIDS in Kenya. The most reliable data come from a series of collaborative studies by the World Health Organization and the Joint United Nations Program on HIV/AIDS (UNAIDS).

In Kenya the HIV virus is most commonly transmitted through unprotected heterosexual intercourse (WHO, 2004). The WHO estimates that in 2007 the adult prevalence of HIV/AIDS in Kenya was between 7.1% and 8.5% and, in the same year, between 85,000 and 130,000 Kenyans died of HIV/AIDS (WHO, 2008). These numbers mask the internal variation of the HIV/AIDS impact in Kenya. The burden of HIV/AIDS within the population of Kenya varies by gender, age, region, and urban versus rural residence. Of the 1.5-2 million people living with HIV/AIDS in Kenya 800,000-1.1 million are women older than age 15, according to WHO estimates (2008). These figures are in line with a concerning global trend popularly known as the “feminization of HIV/AIDS,” or the increasing incidence of infection among women primarily as a result of socially structured gender inequality. The prevalence of HIV/AIDS is greater in rural areas than in urban areas primarily due to lack of education, poverty, and scarcity of health care facilities (WHO, 2004). Finally, HIV/AIDS prevalence varies by region. The highest overall prevalence is on the shores of Lake Victoria in Western Kenya, with a prevalence approaching a staggering 40% (WHO, 2008).

While the picture is bleak, trends have been largely positive. As a result of a massive roll out of Highly Active Anti-Retroviral Therapy (HAART) through the combined efforts of the Kenyan Government, donor nations, NGOs, and the private sector, the mortality rate due to HIV/AIDS in Kenya has declined since the late 1990s (Crum et al, 2006). Addressing the HIV/AIDS epidemic continues to be a major health priority for all stakeholders in Kenya. Review of Additional Public Health Challenges in Kenya In addition to the burden of HIV/AIDS, malaria also presents a health challenge in Kenya, with the age standardized disability adjusted life-years (DALYs) from malaria at 1,797 per 100,000 persons in 2004. A major concern surrounds the low utilization of insecticide treated nets, with only 17.5% of pregnant women sleeping under a treated bed net in a recent survey (WHO, 2011b). Furthermore, the burden of TB is also a major issue with an age standardized burden of 2,577 DALYs per 100,000 persons and an age standardized mortality rate of 129.5 per 100,000 persons (WHO, 2012). There is a further troublesome trend, with nearly 53% of tuberculosis (TB) patients being co-infected with HIV/AIDS (WHO, 2010).

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A lack of quality maternal and child health care services leads to significant morbidity and mortality among Kenyans. Overall, 81% of births occur in rural areas in Kenya; however, utilization of a skilled birth attendant at delivery was 50% less likely when compared to those in mothers in urban areas (WHO, 2008). In 2003, 88.1% of pregnant women had at least one visit with a skilled provider before delivering (WHO, 2008). However, key health indicators for maternal health have stagnated or worsened when compared to 1993 levels. Furthermore, there is a significant gap in utilization of services, with the poorest quintile of women four times less likely to receive skilled health care than the wealthiest quintile. In parallel with key health indicators for maternal health, child health indicators have stagnated or worsened in comparison to 1993 levels. Infant mortality is approximately 40 deaths per 1,000 pregnancies (WHO, 2008). The nutrition transition, the phenomenon where a population shifts from health patterns associated with undernutrition and infectious diseases to health patterns associated with obesity and chronic diseases, is becoming evident in Kenya. (Popkin, 2004 and 2006; Pawloski et al, 2012). As fast foods, in the form of street foods, become an increasing source of energy in Nairobi there is evidence of increasing rates of obesity in urban populations as compared to more rural locations - although rural areas are also experiencing increasing rates of obesity (Pawloski et al, 2012). Spatial analysis demonstrates a clustering of obese mothers and children in urban areas near Nairobi whilst underweight mothers and children appear to cluster in more rural regions and the Northeastern areas. The geographic variability, as well as defined patterns concerning the distribution of obesity and malnutrition among mothers and children in Kenya, suggest the need for further studies to understand the geographic determinants of health in this region and many other low-income countries (Pawloski et al, 2012). An Epidemiologic Transition: The Rise of Non-communicable Diseases With the improvement of the general health and nutritional status of populations around the world and improved access to housing, clean water and sanitation, people are experiencing fewer infectious diseases and are living longer, more productive lives (Reddy and Yusuf, 1998). With the decline in infectious diseases, however, there is often a concomitant rise in the prevalence of chronic, non-communicable diseases (NCDs), particularly cardiovascular disease (CVD) (Reddy and Yusuf, 1998). This shift from infectious diseases to NCDs as the predominant cause of morbidity and mortality within a population is known as the epidemiological transition (Omran, 1971). CVD, which includes ischemic heart disease, cerebrovascular disease, cardiomyopathy, valvular heart disease and pericarditis, is currently the leading cause of death in the world, with 80% of all CVD-related deaths occurring in low- and middle-income countries (LMICs) (Alwan et al, 2010). In a general survey, 40% of deaths due to NCDs in LMICs were in the under-60 age group (Mendis et al, 2011). In contrast, only 11% of NCD-related deaths in high-income countries occurred in individuals under 60 (Mendis et al, 2011). More specifically, CVD in LMICs has been shown to occur at a significantly younger age than that observed in high-income countries, causing individuals to become less productive during their prime working years, subsequently placing considerable strain on local economies (Alwan et al, 2010). In 2002, it was estimated that 43% of global disability-adjusted life years (DALYs), based on worldwide morbidity and mortality rates, were due to CVD (Mbewu and Mbanya, 2006). A later study examining the rates of CVD and other NCDs in 23 LMICs estimated that $84 billion US dollars of economic production would be lost as a result of high rates of heart disease, stroke and diabetes in LMICs between 2006 and 2015 (Abegunde et al, 2007). At the same time, it was noted that the cost per quality adjusted life year (QALY) gained was relatively low when providing secondary CVD prevention (e.g. administering beta-blockers or ACE-inhibitors to prevent CVD in patients with known CVD-associated diseases) in Sub-Saharan African countries (Gaziano, 2005).

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The development of CVD is often attributed to several associated modifiable and non-modifiable CVD risk factors (WHO, 2004). Examples of major modifiable CVD risk factors include high blood pressure, abnormal lipids, tobacco use, physical inactivity, obesity, unhealthy diets and diabetes mellitus (WHO, 2004). Examples of non-modifiable CVD risk factors include advancing age, heredity/family history, gender and race/ethnicity (WHO, 2004). While most developing nations in the world have experienced a rapid rise in the prevalence of ischemic heart disease, countries in Sub-Saharan Africa have, instead, predominantly observed an increase in the prevalence of hemorrhagic strokes and dilated cardiomyopathy (DCM), possibly due to nutritional and/or viral factors (Mbewu and Mbanya, 2006). In several Sub-Saharan African countries, hypertension is highly prevalent, particularly in urban areas, and strokes are the most common complication of hypertension in this region (Forrester et al, 1998). In Kenya, hypertension, which has become increasingly prevalent due to adoption of “Westernized” high salt diets throughout the country, is a common cause of heart failure and cerebrovascular disease (Trowell, 1980). In addition, diabetes represents a moderate problem, with the overall prevalence of diabetes and glucose intolerance in the Kenyan population estimated at 4.2% and 12.0%, respectively (Christensen et al, 2009). Rates of diabetes do, however, vary depending on ethnic group, with the highest prevalence of diabetes observed in the Luo ethnic group (Christensen et al, 2009). Kenya’s age standardized CVD death rate is estimated to be 300-350 deaths per 100,000 population and, while ischemic heart disease is a problem, a disproportionately high percentage of Kenya’s population dies from cerebrovascular disease (Mendis et al, 2011). In Kenya, the age-standardized death rate due to ischemic heart disease is 101.2 per 100,000 population, and the death rate due to cerebrovascular disease is 116.6 per 100,000 population (Mendis et al, 2011). In comparison, in the U.S., the age-standardized death rate due to ischemic heart disease is 80.5 per 100,000 population, and the death rate due to cerebrovascular disease is 25.4 per 100,000 population (Mendis et al, 2011). In Kenya, DCM is another important problem, but interestingly, although half of the patients with DCM have histological signs of previous myocarditis, the myocarditis appears to be autoimmune in origin, rather than due to a viral infection, as is common in other Sub-Saharan African nations (Mbewu and Mbanya, 2006). Endomyocardial fibrosis, a restrictive cardiomyopathy is also more commonly seen in Kenya and other parts of East Africa than in areas outside of this region (Mbewu and Mbanya, 2006). In addition, rheumatic heart disease remains a problem in Kenya (Mbewu and Mbanya, 2006). Unless action is taken to curb Kenya’s emerging CVD epidemic, CVD is likely to become the nation’s largest health problem in the next decade and will place significant strain on the health care system, as well as the nation’s economy as a whole. The Association between CVD and HIV Infection As greater numbers of HIV positive individuals have gained access to antiretroviral (ARV) drugs globally, patients with HIV are living longer and their rates of traditionally age-related chronic NCDs such as CVD have risen significantly (Sharma et al, 2008). The observed increase in CVD risk among HIV positive adults has been attributed to both infection with the HIV virus itself, as well as a side effect of the ARVs used to treat HIV infection (Maggi et al 2009; Stein et al, 2008). Recent studies have shown that HIV positive individuals who have never received ARVs are at an increased risk of developing CVD if their CD4 count falls below 150 cells/mm3 or their HIV viral load rises above 100,000 copies/mL (Maggi et al, 2009). These findings suggest that both the HIV virus itself, as well as the HIV-associated immune response, represent primary risk factors in the development of CVD in HIV infected individuals (Maggi et al, 2009). CVD is also a well-known side effect of certain ARVs used to treat HIV infection (Sabin et al, 2008). One class of ARVs, the protease inhibitors (PIs) (e.g. Kaletra, lopinavir/ritonavir),

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has been particularly implicated in the development of CVD and CVD-associated risk factors among HIV positive patients on ARV treatment (Barbaro 2003; Farrygua et al, 2009). PIs have been demonstrated to increase HIV positive individuals’ risk of developing dyslipidemia, insulin resistance/diabetes mellitus and body fat redistribution (Barbaro 2003; Farrygua et al 2009). Another class of ARVs, the nucleoside reverse transcriptase inhibitors (NRTIs), has also been associated with an increased risk of CVD in HIV positive individuals treated with NRTIs (Sabin et al, 2008). In contrast to other LMICs, where the most common manifestation of CVD among HIV positive patients is coronary artery disease (CAD), in countries in Sub-Saharan Africa, non-ischemic forms of CVD are more prevalent, indicating the need to further explore the relationship between HIV and CVD in individual nations (Ntsekhe and Mayosi, 2009). HEALTH INFRASTRUCTURE & PARTNERSHIPS IN KENYA

Health Infrastructure and Access to Care in Kenya

Kenya’s government-run health care infrastructure includes the national teaching hospital, provincial hospitals, district and sub-district hospitals, health centers, and dispensaries. The system is a hierarchical-pyramidal organization comprising five levels, the lowest being the village dispensary and Kenyatta National Hospital at the apex. Other operators within the private, non-governmental, and traditional or informal sectors also run facilities. The Ministry of Health supervises formulation of policies and enforcement of standards across the country. The country has eight provinces divided into lower levels of administration called districts, which are responsible for delivering health services and implementing health programs. These districts form the central pillars of the public health system.

By the end of 2008, there were 6,190 health facilities, with 16/100,000 population and 11/1,000 km2. An estimated 48% of health facilities were administered by the Government of Kenya (GOK), 13% by Faith Based Organizations (FBOs), 1% by local authorities, 2% by NGOs, 2% by communities themselves and 34% by private companies. The government owns most of the hospitals, health centers and dispensaries, while clinics and nursing homes are entirely in the hands of the private sector. As illustrated by Wamai RG, facilities are unevenly distributed across the country’s seven provinces and Nairobi. The Central province has the best coverage, with a population of 4,194 per health facility, whereas the Western valley has a population of 9,512 per health facility (2009).

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Data from the 2008 Kenya Health Management Information Systems shows additional information for distribution of health facilities in each province:

Health Facility Level

HF/100,000 Population HF/1000 Km2 HF/100,000

Population HF/1000 Km2 HF/100,000 Population HF/1000 Km2

1 0 0 0 0 0 0

2 or 3 13 1 21 8 15 6

4 1 0 1 0 1 0

5 0 0 0 0 0 0

6 0 0 0 0 0 0

Total 15 2 22 9 16 6

Health Facility Level

HF/100,000 Population HF/1000 Km2 HF/100,000

Population HF/1000 Km2 HF/100,000 Population HF/1000 Km2

1 0 0 0 0 0 0

2 or 3 24 87 11 503 11 39

4 1 4 1 58 2 5

5 0 0 0 0 0 0

6 0 0 0 4 0 0

Total 26 91 12 566 13 44

Health Facility Level

HF/100,000 Population HF/1000 Km2 HF/100,000

Population HF/1000 Km2 HF/100,000 Population HF/1000 Km2

1 0 0 0 0 0 0

2 or 3 8 41 16 9 15 10

4 1 4 1 1 1 1

5 0 0 0 0 0 0

6 0 0 0 0 0 0

Total 8 45 17 9 16 11

North Eastern Coast Eastern

Central Nairobi

Western Rift Valley National

Nyanza

Nairobi, the most densely populated region has the highest density of health facilities, with 566/1000 km2, whereas the North-Eastern province has the lowest distribution of health facilities, with 2/1000 km2. Partnerships and Programs in Health

Kenya’s public health infrastructure has been growing rapidly over the past decade. Much of Africa has had difficulty providing proper medical care and facilities for diseases, such as malaria, tuberculosis, HIV/AIDS, and various non-communicable diseases. Kenya has increased its efforts in creating initiatives to address these problems with health care infrastructure. While there are partnerships with countries like the United States that provide aid and personnel to these programs, many of these projects are partnerships among African nations, as well as grassroots organizations. One of the leading public research organizations in Kenya is the Kenya Medical Research Institute, also known as KEMRI (Simiyu et al, 2010). The goal of KEMRI is to promote “quality of health and human life through research” (Simiyu et al, 2010). The organization develops products that are used in addressing local health problems, such as Malaria, HIV/AIDS, and Hepatitis B (Simiyu et al, 2010). Their technologies have provided drugs and equipment to Kenya and many other sub-Saharan African nations (Simiyu et al, 2010). Another leading institute in developing public health care is the African Medical and Research Foundation (AMREF). AMREF is an international African organization that is headquartered in Kenya (AMREF, 2012). Like KEMRI, their goal is to bolster health systems

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and provide easily accessible medical facilities. One of their methods is to foster community relationships by encouraging active participation from citizens, health workers, and government officials (AMREF, 2012). AMREF also partners with the private sector, national governments, and multilateral agencies to increase funding (Sharp, 1998). Two important coalitions between Kenya and the United States are the AIDS, Population and Health Integrated Assistance programs (APHIA) and the President’s Emergency Plan for AIDS Relief (PEPfAR). APHIA is a 5-year program funded by the United States Agency for International Development (APHIA, 2012). Its goals are to provide funding to further develop medical services in HIV/AIDS, Tuberculosis, and malaria, but they also focus on reproductive health, family planning, and maternal and child health (APHIA, 2012). Also providing aid is the U.S. government’s initiative, PEPfAR. PEPfAR was developed to help ease the struggle of those suffering from HIV/AIDS with a focus on prevention efforts, care, and treatment (PEPfAR, 2012). Much of its mission is based around developing programs that are “country-owned” and “country-driven,” allowing countries to establish their own leadership in the health care system. The organization’s goals are centered on establishing sustainable programs that address inefficiencies within the health care system (PEPfAR, 2012).

Kenya continues to develop programs to improve its public health infrastructure. Many African lead organizations are developing technologies and programs to strengthen medical care in Kenya and, with the help from U.S. and other international partnerships, they are working towards creating sustainable initiatives to provide adequate medical care to their citizens.

OPPORTUNITIES & CHALLENGES FOR IMPLEMENTATION PLANS Potential of the Health Worker The shortage of health workers in Kenya presents a major challenge to health development (Chankova et al, 2009). There are only 1.03 health workers (doctors, nurses, midwives, and clinical officers) per 1000 people, well below the 2.30 per 1000 population recommended by the WHO (Kenya’s Health Workforce, 2010). While the Kenyan government has scaled up education and training for health workers in recent years, there are still obstacles to retaining and ensuring an equitable distribution of health workers in the country (Kenya’s Health Workforce 2010; Republic of Kenya Ministry of Health, 2004). The net emigration rate for doctors is 51%, one of the highest in the world (Ndetei et al, 2008). Within the country, the effects of “internal brain drain” can be seen through the disproportionate concentration of health workers in the private sector, even though the public sector serves the majority of Kenyans. Furthermore, more than half of the health workforce and around 80% of doctors are based in urban areas, while almost 80% of Kenyans live in rural areas (Chankova et al, 2009). A number of factors contribute to the internal and external migration of Kenyan health workers. Absenteeism and resignation of health workers have been attributed to poor working conditions, long workdays, and poor remuneration (Chankova et al, 2009). The lack of supplies such as medical equipment and drugs in many facilities impede the ability of health workers to perform their duties (Republic of Kenya Ministry of Health, 2004). Additionally, the HIV epidemic has added stress to an already overextended health workforce. Health workers experience greater occupational stress from dealing with more deaths, fear for safety in the workplace, and fatigue from increased patient load. Limited career and educational opportunities also push health workers and their families away from underserved areas (Ndetei et al, 2008). In light of these challenges, the Kenyan government has recognized strengthening the health workforce as a national priority (Kenya’s Health Workforce, 2010).

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Challenge of Gender-based Violence Gender based violence (GBV) in Kenya presents a difficult challenge as the government heightens its efforts to prevent and respond to escalation of violence in the years following the post-election crisis in 2007-2008, which resulted in the displacement of an estimated 200,468 people amongst 300 camps. Nairobi-based hospitals reported that sexual violence increased during this time of crisis, as efforts to protect women and girls during this time of social disorder were largely ineffective (Myrun, 2009). While Kenya is most certainly acting in response to this pressing global health issue, concerns remain about availability of resources to provide appropriate services for populations both vulnerable to and victims of gender-based violence. The Ministry of Health has emphasized prevention of sexual violence through legislation, advocacy and awareness-raising, as well as provision of post-sexual violence services (SRVI, 2009). For example, the Gender Based Violence Working Group, established initially under the UN with support from the Kenyan government, acts as a consolidator for all activities that aim to prevent or respond to GBV in Kenya (GBV, 2011).

As defined by IASC Guildings for Addressing Gender Based Violence (GBV) in Humanitarian settings, GBV is an umbrella term for any harmful act that is perpetrated against a person’s will, and that is based on socially ascribed (gender) differences between males and females (GBV, 2011). The Kenya Health and Demographic Survey reports that 39 percent of women have experienced physical violence, with almost one in four women having experienced such violence in the 12 months prior to data collection (KNBS, 2010). Additionally, 12 percent of women between ages 15 and 49 reported that their first sexual intercourse was forced against their will. Gender based violence is not limited to sexual and physical abuse, but also includes the practice of female genital cutting. UNICEF statistics state that 36% of rural women aged 15-49 have suffered from genital mutilation (Commis, 2010). Health risks of female genital mutilation include but are not limited to postpartum hemorrhages and an increase in infant mortality. Efforts must be made to improve the capacity to respond to endemics of gender violence, coordinate prevention and response activities at both provincial and district levels, train camp-based staff in GBV prevention, increase security in camps, and integrate GBV awareness into community education.

The Potential Impact of Innovative Technology Innovative technologies are currently being used in African countries to improve the treatment of patients, expand the access to care and to disseminate medical training and knowledge. Current technologies can be classified in three broad categories: (1) medical technologies (2) electronic technologies and (3) mobile technologies. These technologies exist both for treatment and prevention of various diseases, among them cardiovascular disease (CVD). This section will give an overview of these types of technologies that are currently being used in relevant locations to treat diseases and provide for better health care infrastructure. 1. Medical Technologies The World Health Organization (WHO) outlines the essential medical equipment necessary for the detection and prevention of cardiovascular diseases. They suggest the following are necessary resources: stethoscope, accurate blood pressure measurement device, measuring tape and weighing scale, equipment for testing urine glucose and urine albumin, and blood glucose and blood cholesterol assays (WHO, 2007). Medical technologies for the treatment of CVD include pharmaceuticals (statins, beta blockers, insulin, etc.), drug delivery systems, and surgical and clinical devices (WHO, 2007; BD, 2012; Millennium Research Group, 2011). These represent the basics of medical technologies necessary for the treatment and detection of CVD. However, new, cutting-edge devices and technologies are being developed to improve the cardiovascular health of African nations. For example, last year, a South African

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medical device company, Diacoustic Medical Devices, developed a software program to use with an electronic stethoscope for detecting the difference between normal physiological heart murmurs and pathological heart murmurs. The combinatory device was found to be 90% effective at diagnosing abnormal hearth murmurs (Africa Health, 2011). 2. Electronic Technologies (“eHealth”) eHealth is a relatively new approach to address healthcare needs with electronic processes and communications. Examples of these technologies include software programs to keep track of patient medical records, tutorial programs for the education of medical practitioners, and diagnostic programs. In 2005, IntraHealth International, began developing a Human Resources Information System (HRIS) in Uganda and Rwanda to improve information aggregation, data accuracy, data accessibility, and to mitigate inconsistencies, inefficiencies and secretarial costs (IntraHealth International, 2009). The HRIS was shown to effectively increase the leadership, human resources, and strategic planning in Uganda and Rwanda. In 2009, IntraHealth launched Capacity Kenya, with one of its goals to expand the success of the HRIS system to Kenya (IntraHealth International, 2012). Corporations such as General Electric (GE) and 3M have developed health information systems to improve the healthcare in developing countries. 3M offers a range of programs to improve clinical documentation, coding workflow, quality management, classifications, and medical necessities (3M, 2012). GE has developed cardiology specific information systems. One of their premier electronic technology products is the MUSE Cardiology Information System. This technology stores patient data (ECGs, medical history, etc), provides analysis of testing results, and provides a means of reporting and distributing results. 3. Mobile Technologies (“mHealth”) With 5.9 billion global mobile subscribers (87% of the world’s population), mobile technologies provide a new means of accessing patient records and communicating. Mobile technologies allow for improved healthcare of patients in remote areas and the ability to centralize healthcare operations. In 2009, Anvita Health partnered with Google Health and developed a Mobile Viewer built on Google’s Andriod platform. The application can provide real-time health feedback, and important data such as drug interactions. In 2010, IntraHealth International launched a campaign, partnered with Hope Phones and Medic Mobile Collabarate, to provide mobile technologies to health care workers in African nations. This campaign was designed to improve maternal and child health services, and the treatment of communicable diseases (IntraHealth International, 2010). Conclusion This section represents a sample of the innovative technologies that are available to be used in the treatment of CVD. Teams are encouraged to understand the use of these types of products and to find innovative technologies to apply to their solutions.

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ACKNOWLEDGEMENTS 2012 Case Writing Team

• Cheyenne Allenby, Duke University • Mark Dakkak, Duke University • Lisa Deng, Duke University • Ian Hill, North Carolina State University • Jacob Kirkorowicz, Duke University • Rita Kuwahara, UNC-Chapel Hill • Chris Lam, Duke University • Adrienne Yates, North Carolina State University

2012 Case Advisors

• Rebecca Kohler, Maureen Corbett, Leigh Shamblin, Barbara Stilwell, Heather LaGarde, IntraHealth International

• Lee Shirkley, BD • Mamie Sackey Harris, UNC-Chapel Hill • Brian Seavey, Duke Global Health Institute

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