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7.3. The operational model of effectiveness of STI services (Fransen-Piot model)
We did not have the ambition to collect information on all steps of the model. However, our
studies should be considered complimentary to similar earlier data on Nairobi (Rao 1998)
and may help in identifying the barriers. Based on a population of about 2 million, the annual
number of STI cases occurring in Nairobi can be roughly estimated at 225.000. The
proportion of infected individuals becoming symptomatic in our study was not known.
Korenromp et al (2002) have estimated those proportions at 45% for males with NG, 11% for
males with CT, 14% for females with NG and 6% for females with CT in rural Uganda.
However, these estimates were inconsistent with previous direct estimates based on a US
cohort study.
Comprehensive data on the number of patients with STI seeking medical care was not
available. Based on routine surveillance data of the NCC clinics providing STI care, including
the STC, we can estimate the number of annual STI cases seen at those facilities at about
70,000 (Temmerman 1999). Our data indicate that a large part of the STI care is not sought
through public sector clinics, however that proportion is unknown. Data on the proportion of
STI patients seeking medical care who were correctly treated were not available. We tried to
answer this question for women attending with vaginal discharge, and concluded that 42% of
women with CT and/or NG would be correctly diagnosed at first visit. Since all drugs required
for the STI protocols were available during the study period, we can assume that correct
treatment was always administered. A recent study on quality of STI care by different
categories of service providers in Nairobi indicates that correct diagnosis and treatment
varies between 14% and 48% (Voeten 2001). Public clinics equipped for STI care performed
best in all aspects, whereas treatment was poorest in pharmacies and private clinics.
Information on compliance and effectiveness of treatment was not available. As we indicated
that only a minority of cases is treated at public health facilities, correct overall treatment can
therefore be estimated to be very low. Partner notification varies from 12% for STI patients at
the STC clinic to 53% for partners of syphilis seropositive women during pregnancy.
There are obviously too many unknowns to calculate the proportion of patients with STI that
are cured by health services. In Mwanza, where improved STI services are offered in all
health centers, the estimated overall cure rate ranged between 23 and 41% (Buve 2001).
Based on our findings, we can assume that this proportion is probably lower in Nairobi.
We tried to answer the question on the quality of diagnosis of vaginal discharge among those
women attending the health care facilities, by evaluating the performance of the algorithm in
CONCLUSIONS 103