Health disparities across the counties of Kenya and implications for policy makers, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

Molecular and serological diagnosis of multiple bacterial zoonoses in febrile outpatients in Garissa County, north-eastern Kenya

Bacterial zoonoses are diseases caused by bacterial pathogens that can be naturally transmitted between humans and vertebrate animals. They are important causes of non-malarial fevers in Kenya, yet their epidemiology remains unclear. We investigated brucellosis, Q-fever and leptospirosis in the venous blood of 216 malaria-negative febrile patients recruited in two health centres (98 from Ijara and 118 from Sangailu health centres) in Garissa County in north-eastern Kenya. We determined exposure to the three zoonoses using serological (Rose Bengal test for Brucella spp., ELISA for C. burnetti and microscopic agglutination test for Leptospira spp.) and real-time PCR testing and identified risk factors for exposure. We also used non-targeted metagenomic sequencing on nine selected patients to assess the presence of other possible bacterial causes of non-malarial fevers. Considerable PCR positivity was found for Brucella (19.4%, 95% confidence intervals [CI] 14.2-25.5) and Leptospira spp. (1.7%, 95% CI 0.4-4.9), and high endpoint titres were observed against leptospiral serovar Grippotyphosa from the serological testing. Patients aged 5-17 years old had 4.02 (95% CI 1.18-13.70, p-value = 0.03) and 2.42 (95% CI 1.09-5.34, p-value = 0.03) times higher odds of infection with Brucella spp. and Coxiella burnetii than those of ages 35-80. Additionally, patients who sourced water from dams/springs, and other sources (protected wells, boreholes, bottled water, and water pans) had 2.39 (95% CI 1.22-4.68, p-value = 0.01) and 2.24 (1.15-4.35, p-value = 0.02) times higher odds of exposure to C. burnetii than those who used unprotected wells. Streptococcus and Moraxella spp. were determined using metagenomic sequencing. Brucellosis, leptospirosis, Streptococcus and Moraxella infections are potentially important causes of non-malarial fevers in Garissa. This knowledge can guide routine diagnosis, thus helping lower the disease burden and ensure better health outcomes, especially in younger populations.

The effectiveness of community health worker training, equipping, and deployment in reducing COVID-19 infections and deaths in rural Western Kenya: A comparison of two counties

COVID-19 and other pandemics remain significant threats to population health, particularly in rural settings where health systems are disproportionately weak. There is a lack of evidence on whether trained, equipped, and deployed community health workers (CHWs) can lead to significant reductions in COVID-19 infections and deaths. Our objective was to measure the effectiveness of deploying trained and equipped CHWs in reducing COVID-19 infections and deaths by comparing outcomes in two counties in rural Western Kenya, a setting with limited critical care capacity and limited access to COVID-19 vaccines and oral COVID-19 antivirals. In Siaya, trained CHWs equipped with thermometers, pulse oximeters, and KN95 masks, visited households to convey health information about COVID-19 prevention. They screened, isolated, and referred COVID-19 cases to facilities with oxygen capacity. They measured and digitally recorded vital signs at the household level. In Kisii county, the standard Kenya national COVID-19 protocol was implemented. We performed a comparative analysis of differences in CHW skills, activity, and COVID-19 infections and deaths using district health information system (DHIS2) data. Trained Siaya CHWs were more skilled in using pulse oximeters and digitally reporting vital signs at the household level. The mean number of oxygen saturation measurements conducted in Siaya was 24.19 per COVID-19 infection; and the mean number of temperature measurements per COVID-19 infection was 17.08. Siaya CHWs conducted significantly more household visits than Kisii CHWs (the mean monthly CHW household visits in Siaya was 146,648.5, standard deviation 11,066.5 versus 42,644.5 in Kisii, standard deviation 899.5, p value = 0.01). Deploying trained and equipped CHWs in rural Western Kenya was associated with lower risk ratios for COVID-19 infections and deaths: 0.54, 95% CI [0.48-0.61] and 0.29, CI [0.13-0.65], respectively, consistent with a beneficial effect.

YouTube as an information source for bleeding gums: A quantitative and qualitative analysis

Gum bleeding is a common dental problem, and numerous patients seek health-related information on this topic online. The YouTube website is a popular resource for people searching for medical information. To our knowledge, no recent study has evaluated content related to bleeding gums on YouTube™. Therefore, this study aimed to conduct a quantitative and qualitative analysis of YouTube videos related to bleeding gums. A search was performed on YouTube using the keyword "bleeding gums" from Google Trends. Of the first 200 results, 107 videos met the inclusion criteria. The descriptive statistics for the videos included the time since upload, the video length, and the number of likes, views, comments, subscribers, and viewing rates. The global quality score (GQS), usefulness score, and DISCERN were used to evaluate the video quality. Statistical analysis was performed using the Kruskal-Wallis test, Mann-Whitney test, and Spearman correlation analysis. The majority (n = 69, 64.48%) of the videos observed were uploaded by hospitals/clinics and dentists/specialists. The highest coverage was for symptoms (95.33%). Only 14.02% of the videos were classified as "good". The average video length of the videos rated as "good" was significantly longer than the other groups (p <0.05), and the average viewing rate of the videos rated as "poor" (63,943.68%) was substantially higher than the other groups (p <0.05). YouTube videos on bleeding gums were of moderate quality, but their content was incomplete and unreliable. Incorrect and inadequate content can significantly influence patients' attitudes and medical decisions. Effort needs to be expended by dental professionals, organizations, and the YouTube platform to ensure that YouTube can serve as a reliable source of information on bleeding gums.

Kenyan adults with type 2 diabetes mellitus (T2DM) increase diabetic knowledge and self-efficacy and decrease hemoglobina1c levels post-educational program

Introduction

Literature supports the relationship between increased diabetic knowledge and improved health outcomes among individuals with Type II diabetes mellitus (T2DM). In Kenya, knowledge gaps within the at-risk population still exist about the symptoms, complications, and management strategies of T2DM, making it challenging to achieve the required personal and community health levels. The project's objective was to determine whether a structured educational intervention for patients in Eldoret, Kenya, would increase diabetic knowledge and self-efficacy and reduce HbA1c levels.

Method

We utilized an experimental study with a convenience sample of 143 participants systematically grouped into control and experimental. The experimental group only received a structured educational intervention based on the health belief model. Pre- and post-intervention data for diabetic knowledge, self-efficacy, and HbA1c were analyzed using the independent T and ANOVA tests.

Results

We observed significant between-group differences for diabetic knowledge (t (116) = 7.22, p<0.001), self-efficacy t (96)=5.323, p<0.001; and HbA1c level t (121) =-2.87, p =.003. We also observed significant within-group differences for diabetic knowledge, t (12.6), p<0.001); self-efficacy t (5.32), p<.001); and HbA1c, t (4.4), p<0.001, in the experimental group only.

Conclusions

This study reveals the effect of a structured education intervention in increasing diabetic knowledge and self-efficacy while reducing HbA1c levels in T2DM patients in Eldoret, Kenya.

Combating malaria in Kenya through collaborative population health education: a systematic review and pilot case study

BACKGROUND

Malaria continues to be a public health problem in Kenya, with an estimated 37.2 million people at high risk of the disease. The disease burden is compounded by inequalities in health service availability, housing, socioeconomic conditions, and access to education.

OBJECTIVES

We aimed to determine the status of community-based, health education interventions. Based on the findings, to develop an educational module for medical students to combat malaria in Kenya.

METHODS

A systematic review was conducted to identify different educational interventions, their successes and limitations, and legal challenges leading to low uptake and adherence to malaria prevention interventions from 2000-2023. Consequently, a 6-week online educational pilot was conducted with healthcare students from Kenya, Japan, the UK, and Cyprus.

RESULTS

Despite developing a national malaria strategy and monitoring and evaluation strategies, Kenya has not been able to meet the incidence reduction targets set by the World Health Organisation, underscoring the need for more work in identifying the barriers to implementing strategies and optimising the distribution of public health interventions. Student teams proposed innovative solutions, including two-tier malaria control strategies, maternal malaria clinical education, community awareness through schools and NGOs, and a 10-year health system strengthening and immunisation plan.

CONCLUSIONS

Public education regarding prevention strategies and increasing their adoption remains a key challenge in combating malaria in Kenya. In this regard, digital tools can facilitate international collaborative health education and exchange of best practices, allowing students and faculty to engage across boundaries and prepare them to be future-ready physicians connected to the global community.

Spatio-temporal evolution of mortality in Cape Verde: 1995-2018

Located in West Africa, Cabo Verde is a low income country, with significant gains in health indicators. Mortality is an important demographic factor. Its analysis provides essential statistical data for the design, implementation and evaluation of public health programs. The propose of this work is to analyze the spatio-temporal evolution of mortality in Cabo Verde between 1995 to 2018. This is an observational, quantitative study that performs demographic analysis of mortality data from the Ministry of Health of Cabo Verde. Specific mortality rates from standardized causes were calculated considering the population of the country as a reference in the year 2010 and also the standardized rate for all causes on each island, aiming at comparing the islands. During the period under analysis, the number of deaths in men was always higher than that of women. The main causes of death were diseases of the circulatory system and with a higher incidence in women. São Nicolau, Brava, and Santo Antão islands have mortality rates, higher than the national level (2010-2018). The main cause of premature death in women as identified as diseases of the circulatory system, while in men it is injuries, trauma, poisoning and external causes. There was a 72% decrease in the mortality rate due to unclassified symptoms and clinical signs, and an increase in respiratory diseases and tumours. With the exception of diseases of the circulatory system, mortality rates in men are higher than in women for all the considered causes. A decrease in specific mortality rates by age group is expected for both sexes, with a greater gain in men in the younger age groups. With these data, it is intended to alert health decision-makers about the best strategies to be defined in the reduction of mortality in the country.

All-cause and cause-specific mortality rates for Kisumu County: a comparison with Kenya, low-and middle-income countries

Background

Understanding the magnitude and causes of mortality at national and sub-national levels for countries is critical in facilitating evidence-based prioritization of public health response. We provide comparable cause of death data from Kisumu County, a high HIV and malaria-endemic county in Kenya, and compared them with Kenya and low-and-middle income countries (LMICs).

Methods

We analyzed data from a mortuary-based study at two of the largest hospital mortuaries in Kisumu. Mortality data through 2019 for Kenya and all LMICs were downloaded from the Global Health Data Exchange. We provided age-standardized rates for comparisons of all-cause and cause-specific mortality rates, and distribution of deaths by demographics and Global Burden of Disease (GBD) classifications.

Results

The all-cause age-standardized mortality rate (SMR) was significantly higher in Kisumu compared to Kenya and LMICs (1118 vs. 659 vs. 547 per 100,000 population, respectively). Among women, the all-cause SMR in Kisumu was almost twice that of Kenya and double the LMICs rate (1150 vs. 606 vs. 518 per 100,000 population respectively). Among men, the all-cause SMR in Kisumu was approximately one and a half times higher than in Kenya and nearly double that of LMICs (1089 vs. 713 vs. 574 per 100,000 population). In Kisumu and LMICs non-communicable diseases accounted for most (48.0 and 58.1% respectively) deaths, while in Kenya infectious diseases accounted for the majority (49.9%) of deaths. From age 10, mortality rates increased with age across all geographies. The age-specific mortality rate among those under 1 in Kisumu was nearly twice that of Kenya and LMICs (6058 vs. 3157 and 3485 per 100,000 population, respectively). Mortality from injuries among men was at least one and half times that of women in all geographies.

Conclusion

There is a notable difference in the patterns of mortality rates across the three geographical areas. The double burden of mortality from GBD Group I and Group II diseases with high infant mortality in Kisumu can guide prioritization of public health interventions in the county. This study demonstrates the importance of establishing reliable vital registry systems at sub-national levels as the mortality dynamics and trends are not homogeneous.

County Health Leadership Practices and Readiness for Noncommunicable Disease Services in Kenya

Background:

Premature mortality from noncommunicable diseases (NCDs) is a contemporary development challenge. Low-income and lower-middle-income countries are disproportionately affected, with the poorest in society considered the most vulnerable. A paucity of literature exists on how leadership practices at the implementation level relate to ensuring readiness for NCD services.

Objective:

This study investigated any relationship between leadership practices and readiness for NCD services.

Methods:

This correlational study investigated any relationship between leadership practices at the county level and readiness for NCD services in Kenya using secondary data from a 2013 Service Availability and Readiness Assessment survey. Correlation and multiple linear regression tests were used to determine the strength and direction of any relationship between leadership practices (annual work planning, therapeutic committees, and supportive supervision), and NCD readiness (county readiness score).

Findings:

The findings indicated a statistically significant relationship between therapeutic committee (p = .002) and supportive supervision practices (p = .023) and NCD readiness. Leadership practices also had a statistically significant predictive relationship with NCD readiness (p = .009).

Conclusion:

Health leaders should ensure that leadership practices that have a predictive relationship with NCD readiness, such as therapeutic committee activities and supportive supervision visits, are implemented appropriately. Further, county health leaders should pay particular attention to the implementation of these leadership practices at nonpublic and Tiers 2, 3, and 4 health facilities that had lower NCD readiness scores.

Changes in life expectancy and disease burden in Norway, 1990–2019: an analysis of the Global Burden of Disease Study 2019

Background

Methods

Findings

Interpretation

Funding

Effectiveness of an integrated agriculture, nutrition-specific, and nutrition-sensitive program on child growth in Western Kenya: a cluster-randomized controlled trial

BACKGROUND

Stunting rates remain unacceptably high in many regions, including sub-Saharan Africa. Agricultural programs have led to increased yields and household incomes but showed limited success in improving nutritional status.

OBJECTIVES

We assessed whether linear growth could be improved through a potentially scalable, integrated program adding nutrition-specific and nutrition-sensitive components to an existing agricultural program.

METHODS

In this cluster-randomized controlled trial in rural Western Kenya, we randomized children aged 6-35 months from farming families to an agricultural intervention without (control group) or with a bundle of interventions (intervention group), including distribution of micronutrient powders (MNP), poultry to increase egg consumption, seeds of greens and onions, and soap and chlorine solution, as well as provision of monthly behavior change trainings. The primary outcome was the change in height-for-age z-score (HAZ) over 2 years of follow-up. We assessed safety through active morbidity and passive adverse event monitoring. We conducted an intention-to-treat analysis, followed by per-protocol and prespecified subgroup analyses.

RESULTS

From March to April 2018, we enrolled 1927 children from 126 clusters (control, 942 children in 63 clusters; intervention, 985 children in 63 clusters). Data on HAZ were available for 1672 (86.6%) children after 2 years. Adherence was >80% for use of MNP, chlorine, and greens and receipt of soap, and ∼40% for egg and red onion consumption. The intention-to-treat analysis indicated a greater change in HAZ over 2 years in the intervention group (adjusted effect size, 0.11; 95% CI: 0.02-0.19). We found a slightly stronger effect in the per-protocol analysis (adjusted effect size, 0.15; 95% CI: 0.06-0.24). Dietary diversity and consumption of iron-rich foods were improved in the intervention group, and reported instances of fever, lower respiratory tract infections, and diarrheal episodes were lower in the intervention group.

CONCLUSIONS

This study found a modest improvement in linear growth, indicating the need for multiple, integrated interventions to achieve benefits. The trial was registered with clinicaltrials.gov as NCT03448484.

Public Knowledge and Perception of Drinking Water Quality and Its Health Implications: An Example from the Makueni County, South-Eastern Kenya

Due to the semi-arid nature of Makueni County in South-Eastern Kenya, there is a high dependence on groundwater resources for domestic use. Reliance on this source of potable water may have health implications for the population, given the presence of several naturally occurring and potentially harmful elements reported from aquifer source rocks, soil, and water in the area. A survey involving questionnaires and focus group discussions (FGDs) was conducted with 115 individuals to determine the local population’s knowledge, attitude, and perceptions of their drinking water quality and its health impacts. The results show that most respondents (67%) preferred piped water because it was pre-treated and not saline. Only 29% of the respondents were very satisfied with the taste of their drinking water, while the rest complained about varying salinity levels, ranging from slightly salty to very salty. This low satisfaction might have influenced the low daily drinking water consumption (1–2 L) by most respondents. Health issues reported by many (43%) respondents in the area include diarrhoea and gastrointestinal upsets, which may be associated with the saline nature of the drinking water. Elevated fluoride (F−) in the local groundwater was reported, and the health effects remain a concern. Although 91% knew someone with dental fluorosis, 53% did not know the deleterious effects of high F− in drinking water. Most respondents (59%) associated the salty nature of the water with dental fluorosis, and as a result, 48% avoided drinking the salty water to prevent the condition. Despite the high prevalence and known psycho-social effects, most people did not perceive dental fluorosis as a severe health threat. The increased health risks associated with high salinity and high F− in drinking water in Makueni County are poorly understood by most residents, regardless of their education, gender, or age. This warrants an immediate public health education programme and detailed epidemiological studies to determine all the health effects associated with naturally occurring, potentially harmful elements in groundwater in the area.

The status and future of emergency care in the Republic of Kenya

Kenya is a rapidly developing country with a growing economy and evolving health care system. In the decade since the last publication on the state of emergency care in Kenya, significant developments have occurred in the country's approach to emergency care. Importantly, the country decentralized most health care functions to county governments in 2013. Despite the triple burden of traumatic, communicable, and non-communicable diseases, the structure of the health care system in the Republic of Kenya is evolving to adapt to the important role for the care of emergent medical conditions. This report provides a ten-year interval update on the current state of the development of emergency medical care and training in Kenya, and looks ahead towards areas for growth and development. Of particular focus is the role emergency care plays in Universal Health Coverage, and adapting to challenges from the devolution of health care.

A Narrative Review of Kenya's Surgical Capacity Using the Lancet Commission on Global Surgery's Indicator Framework

Surgery, anesthesia, and obstetric (SAO) care is quickly being recognized for its critical role in cost-effectively improving global morbidity and mortality. Six core indicators for SAO capacity were established in 2015 by the Lancet Commission on Global Surgery (LCoGS) and include: SAO provider density, population proximity to surgery-ready facilities, annual national operative volume, a system to track perioperative mortality rate, and protection from impoverishing and catastrophic expenditures. The surgical capacity of Kenya, a lower-middle-income country, has not been evaluated using this framework. Our goal was to review published literature on surgery in Kenya to assess the country's surgical capacity and system strength. A narrative review of the relevant literature provided estimates for each LCoGS indicator. While progress has been made in expanding access to care across the country, key steps remain in the effort to provide equitable, affordable, and timely care to Kenya's population through universal health coverage. Additional investment into training SAO providers, operative infrastructure, and accessibility are recommended through a national surgery, obstetric, and anesthesia plan.

Leading causes of death and high mortality rates in an HIV endemic setting (Kisumu county, Kenya, 2019)

BACKGROUND

In resource-limited settings, underlying causes of death (UCOD) often are not ascertained systematically, leading to unreliable mortality statistics. We reviewed medical charts to establish UCOD for decedents at two high volume mortuaries in Kisumu County, Kenya, and compared ascertained UCOD to those notified to the civil registry.

METHODS

Medical experts trained in COD certification examined medical charts and ascertained causes of death for 456 decedents admitted to the mortuaries from April 16 through July 12, 2019. Decedents with unknown HIV status or who had tested HIV-negative >90 days before the date of death were tested for HIV. We calculated annualized all-cause and cause-specific mortality rates grouped according to global burden of disease (GBD) categories and separately for deaths due to HIV/AIDS and expressed estimated deaths per 100,000 population. We compared notified to ascertained UCOD using Cohen's Kappa (κ) and assessed for the independence of proportions using Pearson's chi-squared test.

FINDINGS

The four leading UCOD were HIV/AIDS (102/442 [23.1%]), hypertensive disease (41/442 [9.3%]), other cardiovascular diseases (23/442 [5.2%]), and cancer (20/442 [4.5%]). The all-cause mortality rate was 1,086/100,000 population. The highest cause-specific mortality was in GBD category II (noncommunicable diseases; 516/100,000), followed by GBD I (communicable, perinatal, maternal, and nutritional; 513/100,000), and III (injuries; 56/100,000). The HIV/AIDS mortality rate was 251/100,000 population. The proportion of deaths due to GBD II causes was higher among females (51.9%) than male decedents (42.1%; p = 0.039). Conversely, more men/boys (8.6%) than women/girls (2.1%) died of GBD III causes (p = 0.002). Most of the records with available recorded and ascertained UCOD (n = 236), 167 (70.8%) had incorrectly recorded UCOD, and agreement between notified and ascertained UCOD was poor (29.2%; κ = 0.26).

CONCLUSIONS

Mortality from infectious diseases, especially HIV/AIDS, is high in Kisumu County, but there is a shift toward higher mortality from noncommunicable diseases, possibly reflecting an epidemiologic transition and improving HIV outcomes. The epidemiologic transition suggests the need for increased focus on controlling noncommunicable conditions despite the high communicable disease burden. The weak agreement between notified and ascertained UCOD could lead to substantial inaccuracies in mortality statistics, which wholly depend on death notifications.

Pediatric Medical Emergencies and Injury Prevention Practices in the Pediatric Emergency Unit of Kenyatta National Hospital, Nairobi, Kenya

INTRODUCTION

The epidemiology and presence of pediatric medical emergencies and injury prevention practices in Kenya and resource-limited settings are not well understood. This is a barrier to planning and providing quality emergency care within the local health systems. We performed a prospective, cross-sectional study to describe the epidemiology of case encounters to the pediatric emergency unit (PEU) at Kenyatta National Hospital in Nairobi, Kenya; and to explore injury prevention measures used in the population.

METHODS

Patients were enrolled prospectively using systematic sampling over four weeks in the Kenyatta National Hospital PEU. Demographic data, PEU visit data and lifestyle practices associated with pediatric injury prevention were collected directly from patients or guardians and through chart review. Data were analyzed with descriptive statistics with stratification based on pediatric age groups.

RESULTS

Of the 332 patients included, the majority were female (56%) and 76% were under 5 years of age. The most common presenting complaints were cough (40%) fever (34%), and nausea/vomiting (19%). The most common PEU diagnoses were upper respiratory tract infections (27%), gastroenteritis (11%), and pneumonia (8%). The majority of patients (77%) were discharged from the PEU, while 22% were admitted. Regarding injury prevention practices, the majority (68%) of guardians reported their child never used seatbelts or car seats. Of 68 patients that rode bicycles/motorbikes, one reported helmet use. More than half of caregivers cook at potentially dangerous heights; 59% use ground/low level stoves.

CONCLUSIONS

Chief complaints and diagnoses in the PEU population were congruent with communicable disease burdens seen globally. Measures for primary injury prevention were reported as rarely used in the sample studied. The epidemiology described by this study provides a framework for improving public health education and provider training in resource-limited settings.

Causes of death in HIV-infected and HIV-uninfected children aged under-five years in western Kenya

OBJECTIVES

Describe the causes of death among infants and children less than 5 years stratified by HIV status.

DESIGN

Cross-sectional analysis of causes of death ascertained through minimally invasive tissue sampling (MITS) in the Kenya Child Health and Mortality Prevention Surveillance site.

METHODS

We included decedents aged 28 days to less than 5 years, whose death was reported within 36 h, underwent MITS, and had HIV test results and causes of death determined. MITS specimens were tested using Taqman Array Cards, culture, cytology, histopathology and immunohistochemistry and HIV PCR. A panel evaluated epidemiologic, clinical, verbal autopsy and laboratory data to assign causes of death using ICD-10 guidelines. Causes of death and etiological agents were stratified by HIV status.

RESULTS

Of 176 included decedents, 14% (n = 25) were HIV-infected, median viral load was 112 205 copies/ml [interquartile range (IQR) = 9349-2 670 143). HIV-disease (96%; n = 24) and malnutrition (23%; n = 34) were the leading underlying causes of death in HIV-infected and HIV-uninfected decedents, respectively. Malnutrition was more frequent in the causal chain of HIV-infected (56%; n = 14) than HIV-uninfected decedents (31%; n = 49) (P value = 0.03). Viral pneumonia was twice as common in HIV-infected (50%; n = 9) than HIV-uninfected decedents (22%; n = 7) (P value = 0.04).

CONCLUSION

Nearly all HIV-infected decedents' underlying cause of death was HIV disease, which was associated with malnutrition. Our findings underscore the need for strengthening early identification and management of HIV-infected children. Prevention, early diagnosis and treatment of malnutrition could be instrumental in improving the survival of HIV-infected and HIV-uninfected children.

Disrupted Service Delivery? The Impact of Conflict on Antenatal Care Quality in Kenya

Introduction: African countries facing conflict have higher levels of maternal mortality. Understanding the gaps in the utilization of high-quality maternal health care is essential to improving maternal survival in these states. Few studies have estimated the impact of conflict on the quality of health care. In this study, we estimated the impact of conflict on the quality of health care in Kenya, a country with multiple overlapping conflicts and significant disparities in maternal survival.

Materials and Methods: We drew on data on the observed quality of 553 antenatal care (ANC) visits between January and April 2010. Process quality was measured as the percentage of elements of client–provider interactions performed in these visits. For structural quality, we measured the percentage of required components of equipment and infrastructure and the management and supervision in the facility on the day of the visit. We spatially linked the analytical sample to conflict events from January to April 2010. We modeled the quality of ANC as a function of exposure to conflict using spatial difference-in-difference models.

Results: ANC visits that occurred in facilities within 10,000 m of any conflict event in a high-conflict month received 18–21 percentage points fewer components of process quality on average and had a mean management and supervision score that was 12.8–13.5 percentage points higher. There was no significant difference in the mean equipment and infrastructure score at the 5% level. The positive impact of conflict exposure on the quality of management and supervision was driven by rural facilities. The quality of management and supervision and equipment and infrastructure did not modify the impact of conflict on process quality.

Discussion: Our study demonstrates the importance of designing maternal health policy based on the context-specific evidence on the mechanisms through which conflict affects health care. In Kenya, deterioration of equipment and infrastructure does not appear to be the main mechanism through which conflict has affected ANC quality. Further research should focus on better understanding the determinants of the gaps in process quality in conflict-affected settings, including provider motivation, competence, and incentives.

High HIV prevalence among decedents received by two high-volume mortuaries in Kisumu, western Kenya, 2019

Background

Accurate data on HIV-related mortality are necessary to evaluate the impact of HIV interventions. In low- and middle-income countries (LMIC), mortality data obtained through civil registration are often of poor quality. Though not commonly conducted, mortuary surveillance is a potential complementary source of data on HIV-associated mortality.

Methods

During April-July 2019, we assessed HIV prevalence, the attributable fraction among the exposed, and the population attributable fraction among decedents received by two high-volume mortuaries in Kisumu County, Kenya, where HIV prevalence in the adult population was estimated at 18% in 2019 with high ART coverage (76%). Stillbirths were excluded. The two mortuaries receive 70% of deaths notified to the Kisumu East civil death registry; this registry captures 45% of deaths notified in Kisumu County. We conducted hospital chart reviews to determine the HIV status of decedents. Decedents without documented HIV status, including those dead on arrival, were tested using HIV antibody tests or polymerase chain reaction (PCR) consistent with national HIV testing guidelines. Decedents aged less than 15 years were defined as children. We estimated annual county deaths by applying weights that incorporated the study period, coverage of deaths, and mortality rates observed in the study.

Results

The two mortuaries received a total of 1,004 decedents during the study period, of which 95.1% (955/1004) were available for study; 89.1% (851/955) of available decedents were enrolled of whom 99.4% (846/851) had their HIV status available from medical records and post-mortem testing. The overall population-based, age- and sex-adjusted mortality rate was 12.4 per 1,000 population. The unadjusted HIV prevalence among decedents was 28.5% (95% confidence interval (CI): 25.5–31.6). The age- and sex-adjusted mortality rate in the HIV-infected population (40.7/1000 population) was four times higher than in the HIV-uninfected population (10.2/1000 population). Overall, the attributable fraction among the HIV-exposed was 0.71 (95% CI: 0.66–0.76) while the HIV population attributable fraction was 0.17 (95% CI: 0.14–0.20). In children the attributable fraction among the exposed and population attributable fraction were 0.92 (95% CI: 0.89–0.94) and 0.11 (95% CI: 0.08–0.15), respectively.

Conclusions

Over one quarter (28.5%) of decedents received by high-volume mortuaries in western Kenya were HIV-positive; overall, HIV was considered the cause of death in 17% of the population (19% of adults and 11% of children). Despite substantial scale-up of HIV services, HIV disease remains a leading cause of death in western Kenya. Despite progress, increased efforts remain necessary to prevent and treat HIV infection and disease.

The impact of child health interventions and risk factors on child survival in Kenya, 1993-2014: a Bayesian spatio-temporal analysis with counterfactual scenarios

BACKGROUND

During the millennium development goals period, reduction in under-five mortality (U5M) and increases in child health intervention coverage were characterised by sub-national disparities and inequities across Kenya. The contribution of changing risk factors and intervention coverage on the sub-national changes in U5M remains poorly defined.

METHODS

Sub-national county-level data on U5M and 43 factors known to be associated with U5M spanning 1993 and 2014 were assembled. Using a Bayesian ecological mixed-effects regression model, the relationships between U5M and significant intervention and infection risk ecological factors were quantified across 47 sub-national counties. The coefficients generated were used within a counterfactual framework to estimate U5M and under-five deaths averted (U5-DA) for every county and year (1993-2014) associated with changes in the coverage of interventions and disease infection prevalence relative to 1993.

RESULTS

Nationally, the stagnation and increase in U5M in the 1990s were associated with rising human immunodeficiency virus (HIV) prevalence and reduced maternal autonomy while improvements after 2006 were associated with a decline in the prevalence of HIV and malaria, increase in access to better sanitation, fever treatment-seeking rates and maternal autonomy. Reduced stunting and increased coverage of early breastfeeding and institutional deliveries were associated with a smaller number of U5-DA compared to other factors while a reduction in high parity and fully immunised children were associated with under-five lives lost. Most of the U5-DA occurred after 2006 and varied spatially across counties. The highest number of U5-DA was recorded in western and coastal Kenya while northern Kenya recorded a lower number of U5-DA than western. Central Kenya had the lowest U5-DA. The deaths averted across the different regions were associated with a unique set of factors.

CONCLUSION

Contributions of interventions and risk factors to changing U5M vary sub-nationally. This has important implications for targeting future interventions within decentralised health systems such as those operated in Kenya. Targeting specific factors where U5M has been high and intervention coverage poor would lead to the highest likelihood of sub-national attainment of sustainable development goal (SDG) 3.2 on U5M in Kenya.

Caregiver experiences and healthcare worker perspectives of accessing healthcare for low-birthweight

BACKGROUND

Low-birthweight (LBW) infants (<2500 g) are at greatest risk of mortality in the neonatal period, particularly in low- and middle-income countries. Timely access to quality healthcare averts adverse outcomes.

AIM

To explore caregiver experiences and healthcare provider perspectives of accessing healthcare for LBW infants in rural Kenya.

METHODS

This qualitative study was undertaken in Homa Bay County of in rural western Kenya in June 2019. In-depth interviews with eleven caregivers and four healthcare providers were conducted by a trained research assistant. All interviews were transcribed verbatim, and transcripts in the local languages were translated into English. A thematic framework was used to analyse the data.

RESULTS

At the community and individual level,community misconceptions about LBW infants, inadequate infant care practices after discharge, lack of maternal support networks, long distances from healthcare facilities and lack of financial support were key challenges. In addition, long hospital waiting times, healthcare worker strikes and the apparent inadequate knowledge and skills of healthcare providers were disincentives among caregivers. Among healthcare providers, health system deficiencies (staff shortages and inadequate resources for optimal assessment and treatment of LBW infants) and maternal illiteracy were key challenges. Education by staff during antenatal visits and community support groups were enablers.

CONCLUSION

Accessing healthcare for LBW infants in this community is fraught with challenges which have implications for their post-discharge outcome. There is an urgent need to develop and test strategies to address the barriers at the community and health system level to optimise outcome..

Integrated screening and treatment services for HIV, hypertension and diabetes in Kenya: assessing the epidemiological impact and cost-effectiveness from a national and regional perspective

INTRODUCTION

As people with HIV age, prevention and management of other communicable and non-communicable diseases (NCDs) will become increasingly important. Integration of screening and treatment for HIV and NCDs is a promising approach for addressing the dual burden of these diseases. The aim of this study was to assess the epidemiological impact and cost-effectiveness of a community-wide integrated programme for screening and treatment of HIV, hypertension and diabetes in Kenya.

METHODS

Coupling a microsimulation of cardiovascular diseases (CVDs) with a population-based model of HIV dynamics (the Spectrum), we created a hybrid HIV/CVD model. Interventions were modelled from year 2019 (baseline) to 2023, and population was followed to 2033. Analyses were carried at a national level and for three selected regions (Nairobi, Coast and Central).

RESULTS

At a national level, the model projected 7.62 million individuals living with untreated hypertension, 692,000 with untreated diabetes and 592,000 individuals in need of ART in year 2018. Improving ART coverage from 68% at baseline to 88% in 2033 reduced HIV incidence by an estimated 64%. Providing NCD treatment to 50% of diagnosed cases from 2019 to 2023 and maintaining them on treatment afterwards could avert 116,000 CVD events and 43,600 CVD deaths in Kenya over the next 15 years. At a regional level, the estimated impact of expanded HIV services was highest in Nairobi region (averting 42,100 HIV infections compared to baseline) while Central region experienced the highest impact of expanded NCD treatment (with a reduction of 22,200 CVD events). The integrated HIV/NCD intervention could avert 7.76 million disability-adjusted-life-years (DALYs) over 15 years at an estimated cost of $6.68 billion ($445.27 million per year), or $860.30 per DALY averted. At a cost-effectiveness threshold of $2,010 per DALY averted, the probability of cost-effectiveness was 0.92, ranging from 0.71 in Central to 0.92 in Nairobi region.

CONCLUSIONS

Integrated screening and treatment of HIV and NCDs can be a cost-effective and impactful approach to save lives of people with HIV in Kenya, although important variation exists at the regional level. Containing the substantial costs required for scale-up will be critical for management of HIV and NCDs on a national scale.

An assessment of non-communicable disease mortality among adults in Eastern Uganda, 2010-2016

BACKGROUND

There is a dearth of studies assessing non-communicable disease (NCD) mortality within population-based settings in Uganda. We assessed mortality due to major NCDs among persons ≥ 30 years in Eastern Uganda from 2010 to 2016.

METHODS

The study was carried out at the Iganga-Mayuge health and demographic surveillance site in the Iganga and Mayuge districts of Eastern Uganda. Information on cause of death was obtained through verbal autopsies using a structured questionnaire to conduct face-face interviews with carers or close relatives of the deceased. Physicians assigned likely cause of death using ICD-10 codes. Age-adjusted mortality rates were calculated using direct method, with the average population across the seven years of the study (2010 to 2016) as the standard. Age categories of 30-40, 41-50, 51-60, 61-70, and ≥ 71 years were used for standardization.

RESULTS

A total of 1,210 deaths among persons ≥ 30 years old were reported from 2010 to 2016 (50.7% among women). Approximately 53% of all deaths were due to non-communicable diseases, 31.8% due to communicable diseases, 8.2% due to injuries, and 7% due to maternal-related deaths or undetermined causes. Cardiovascular diseases accounted for the largest proportion of NCD deaths in each year, and women had substantially higher cardiovascular disease mortality rates compared to men. Conversely, women had lower diabetes mortality rates than men for five of the seven years examined.

CONCLUSIONS

Non-communicable diseases are major causes of death among adults in Iganga and Mayuge; and cardiovascular diseases and diabetes are leading causes of NCD deaths. Efforts are needed to tackle NCD risk factors and provide NCD care to reduce associated burden and premature mortality.

Improved blood pressure control via a novel chronic disease management model of care in sub‐Saharan Africa: Real‐world program implementation results

A chronic disease management model of care (Empower Health) was launched in rural and urban areas of Ghana and Kenya in 2018. The goal was to improve disease awareness, reduce the burden of disease, and improve the clinical effectiveness and efficiency of managing hypertension. Leveraging the model, clinicians provide patients with tailored management plans. Patients accessed regular blood pressure checks at home, at the clinic, or at community‐partner locations where they received real‐time feedback. On the mobile application, clinicians viewed patient data, provided direct patient feedback, and wrote electronic prescriptions accessible through participating pharmacies. To date, 1266 patients had been enrolled in the “real‐world” implementation cohort and followed for an average of 351 ± 133 days across 5 facilities. Average baseline systolic blood pressure (SBP) was 145 ± 21 mmHg in the overall cohort and 159 ± 16 mmHg in the subgroup with uncontrolled hypertension (n = 743) as defined by baseline SBP ≥ 140 mmHg. SBP decreased significantly through 12 months in both the overall cohort (−9.4 mmHg, p < .001) and in the uncontrolled subgroup (−17.6 mmHg, p < .001). The proportion patients with controlled pressure increased from 46% at baseline to 77% at 12 months (p < .001). In summary, a new chronic disease management model of care improved and sustained blood pressure control to 12 months, especially in those with elevated blood pressure at enrollment.

Reframing Non-Communicable Diseases and Injuries for Equity in the Era of Universal Health Coverage: Findings and Recommendations from the Kenya NCDI Poverty Commission

Background

Kenya has implemented a robust response to non-communicable diseases and injuries (NCDIs); however, key gaps in health services for NCDIs still exist in the attainment of Universal Health Coverage (UHC). The Kenya Non-Communicable Diseases and Injury (NCDI) Poverty Commission was established to estimate the burden of NCDIs, determine the availability and coverage of health services, prioritize an expanded set of NCDI conditions, and propose cost-effective and equity-promoting interventions to avert the health and economic consequences of NCDIs in Kenya.

Methods

Burden of NCDIs in Kenya was determined using desk review of published literature, estimates from the Global Burden of Disease Study, and secondary analysis of local health surveillance data. Secondary analysis of nationally representative surveys was conducted to estimate current availability and coverage of services by socioeconomic status. The Commission then conducted a structured priority setting process to determine priority NCDI conditions and health sector interventions based on published evidence.

Findings

There is a large and diverse burden of NCDIs in Kenya, with the majority of disability-adjusted life-years occurring before age of 40. The poorest wealth quintiles experience a substantially higher deaths rate from NCDIs, lower coverage of diagnosis and treatment for NCDIs, and lower availability of NCDI-related health services. The Commission prioritized 14 NCDIs and selected 34 accompanying interventions for recommendation to achieve UHC. These interventions were estimated to cost $11.76 USD per capita annually, which represents 15% of current total health expenditure. This investment could potentially avert 9,322 premature deaths per year by 2030.

Conclusions and Recommendations

An expanded set of priority NCDI conditions and health sector interventions are required in Kenya to achieve UHC, particularly for disadvantaged socioeconomic groups. We provided recommendations for integration of services within existing health services platforms and financing mechanisms and coordination of whole-of-government approaches for the prevention and treatment of NCDIs.

Mapping of anaemia prevalence among pregnant women in Kenya (2016-2019)

BACKGROUND

Reducing the burden of anaemia is a critical global health priority that could improve maternal outcomes amongst pregnant women and their neonates. As more counties in Kenya commit to universal health coverage, there is a growing need for optimal allocation of the limited resources to sustain the gains achieved with the devolution of healthcare services. This study aimed to describe the spatio-temporal patterns of maternal anaemia prevalence in Kenya from 2016 to 2019.

METHODS

Quarterly reported sub-county level maternal anaemia cases from January 2016 - December 2019 were obtained from the Kenyan District Health Information System. A Bayesian hierarchical negative binomial spatio-temporal conditional autoregressive (CAR) model was used to estimate maternal anaemia prevalence by sub-county and quarter. Spatial and temporal correlations were considered by assuming a conditional autoregressive and a first-order autoregressive process on sub-county and seasonal specific random effects, respectively.

RESULTS

The overall estimated number of pregnant women with anaemia increased by 90.1% (95% uncertainty interval [95% UI], 89.9-90.2) from 155,539 cases in 2016 to 295,642 cases 2019. Based on the WHO classification criteria, the proportion of sub-counties with normal prevalence decreased from 28.0% (95% UI, 25.4-30.7) in 2016 to 5.4% (95% UI, 4.1-6.7) in 2019, whereas moderate anaemia prevalence increased from 16.8% (95% UI, 14.7-19.1) in 2016 to 30.1% (95% UI, 27.5-32.8) in 2019 and severe anaemia prevalence increased from 7.0% (95% UI, 5.6-8.6) in 2016 to 16.6% (95% UI, 14.5-18.9) in 2019. Overall, 45.1% (95% UI: 45.0-45.2) of the estimated cases were in malaria-endemic sub-counties, with the coastal endemic zone having the highest proportion 72.8% (95% UI: 68.3-77.4) of sub-counties with severe prevalence.

CONCLUSION

As the number of women of reproductive age continues to grow in Kenya, the use of routinely collected data for accurate mapping of poor maternal outcomes remains an integral component of a functional maternal health strategy. By unmasking the sub-county disparities often concealed by national and county estimates, our study findings reiterate the importance of maternal anaemia prevalence as a metric for estimating malaria burden and offers compelling policy implications for achieving national nutritional targets.

Forecasting disability-adjusted life years for chronic diseases: reference and alternative scenarios of salt intake for 2017-2040 in Japan

BACKGROUND

In Japan, a high-sodium diet is the most important dietary risk factor and is known to cause a range of health problems. This study aimed to forecast Japan's disability-adjusted life year (DALYs) for chronic diseases that would be associated with high-sodium diet in different future scenarios of salt intake. We modelled DALY forecast and alternative future scenarios of salt intake for cardiovascular diseases (CVDs), chronic kidney diseases (CKDs), and stomach cancer (SC) from 2017 to 2040.

METHODS

We developed a three-component model of disease-specific DALYs: a component on the changes in major behavioural and metabolic risk predictors including salt intake; a component on the income per person, educational attainment, and total fertility rate under 25 years; and an autoregressive integrated moving average model to capture the unexplained component correlated over time. Data on risk predictors were obtained from Japan's National Health and Nutrition Surveys and from the Global Burden of Disease Study 2017. To generate a reference forecast of disease-specific DALY rates for 2017-2040, we modelled the three diseases using the data for 1990-2016. Additionally, we generated better, moderate, and worse scenarios to evaluate the impact of change in salt intake on the DALY rate for the diseases.

RESULTS

In our reference forecast, the DALY rates across all ages were predicted to be stable for CVDs, continuously increasing for CKDs, and continuously decreasing for SC. Meanwhile, the age group-specific DALY rates for these three diseases were forecasted to decrease, with some exceptions. Except for the ≥70 age group, there were remarkable differences in DALY rates between scenarios, with the best scenario having the lowest DALY rates in 2040 for SC. This represents a wide scope of future trajectories by 2040 with a potential for tremendous decrease in SC burden.

CONCLUSIONS

The gap between scenarios provides some quantification of the range of policy impacts on future trajectories of salt intake. Even though we do not yet know the policy mix used to achieve these scenarios, the result that there can be differences between scenarios means that policies today can have a significant impact on the future DALYs.

Willingness to participate in future HIV vaccine trials among men who have sex with men and female sex workers living in Nairobi, Kenya

Objective

To evaluate factors associated with willingness to participate in future HIV vaccine trials among men who have sex with men and female sex workers living in Nairobi, Kenya.

Background

Working with ‘key populations’, those at elevated risk of HIV acquisition, is important to conduct efficient HIV prevention trials. In Nairobi Kenya, HIV infection is higher in men who have sex with men (MSM) and female sex workers (FSW) than in the general adult population, hence the need to establish if they would be willing to participate in future HIV vaccine trials.

Methods

We administered a structured questionnaire to MSM and FSW enrolled in a simulated vaccine efficacy trial (SiVET). The SiVET was an observational study designed to mimic the rigors of a clinical trial to assess HIV risk characteristics at baseline. After 12–15 months of follow-up, a structured questionnaire was administered to evaluate hypothetical willingness to participate in future HIV vaccine trials.

Results

Of 250 persons (80% MSM by design) enrolled in SiVET, 214 attended the final study visit and 174 (81%) of them expressed hypothetical willingness to participate in future HIV vaccine trials. These were 82% of MSM and 80% of FSW of those who attended the final study visit. Having a very good experience in the SiVET trial predicted willingness to participate in future HIV vaccine trials. Motivating factors for participation included a desire to receive education about HIV (59%) and to receive healthcare (57%).

Conclusions

Our data demonstrate high willingness among key populations in Kenya, to participate in future HIV vaccine trials after completing participation in a SiVET. The findings suggest that these groups might be a reliable target population for consideration in future HIV vaccine trials. Assessment of willingness to participate in these populations provides important information that may help to inform future education and recruitment efforts for vaccine trials. Improving the research experience for members of key populations could impact their willingness to participate in HIV vaccine trials.

Bayesian hierarchical modeling of joint spatiotemporal risk patterns for Human Immunodeficiency Virus (HIV) and Tuberculosis (TB) in Kenya

The simultaneous spatiotemporal modeling of multiple related diseases strengthens inferences by borrowing information between related diseases. Numerous research contributions to spatiotemporal modeling approaches exhibit their strengths differently with increasing complexity. However, contributions that combine spatiotemporal approaches to modeling of multiple diseases simultaneously are not so common. We present a full Bayesian hierarchical spatio-temporal approach to the joint modeling of Human Immunodeficiency Virus and Tuberculosis incidences in Kenya. Using case notification data for the period 2012–2017, we estimated the model parameters and determined the joint spatial patterns and temporal variations. Our model included specific and shared spatial and temporal effects. The specific random effects allowed for departures from the shared patterns for the different diseases. The space-time interaction term characterized the underlying spatial patterns with every temporal fluctuation. We assumed the shared random effects to be the structured effects and the disease-specific random effects to be unstructured effects. We detected the spatial similarity in the distribution of Tuberculosis and Human Immunodeficiency Virus in approximately 29 counties around the western, central and southern regions of Kenya. The distribution of the shared relative risks had minimal difference with the Human Immunodeficiency Virus disease-specific relative risk whereas that of Tuberculosis presented many more counties as high-risk areas. The flexibility and informative outputs of Bayesian Hierarchical Models enabled us to identify the similarities and differences in the distribution of the relative risks associated with each disease. Estimating the Human Immunodeficiency Virus and Tuberculosis shared relative risks provide additional insights towards collaborative monitoring of the diseases and control efforts.

Cost-related unmet need for healthcare services in Kenya

Background

The assessment of unmet need is one way to gauge inequities in access to healthcare services. While there are multiple reasons for unmet need, financial barriers are a major reason particularly in low- and middle-income countries where healthcare systems do not offer financial protection. Moreover, accessibility and affordability are paramount in achieving universal health coverage. This study examines the extent of unmet need in Kenya due to financial barriers, the associated determinants, and the influence of regional variations.

Methods

We use data from the 2013 Kenya household health expenditure and utilization (KHHEUS) cross sectional survey. Self-reported unmet need due to lack of money and high costs of care is used to compute the outcome of interest. A multilevel regression model is employed to assess the determinants of cost-related unmet need, confounding for the effect of variations at the regional level.

Results

Cost-related barriers are the main cause of unmet need for outpatient and inpatient services, with wide variations across the counties. A positive association between county poverty rates and cost-related unmet is noted. Results reveal a higher intraclass correlation coefficient (ICC) of 0.359(35.9%) for inpatient services relative to 0.091(9.1%) for outpatient services. Overall, differences between counties accounted for 9.4% (ICC ~ 0.094) of the total variance in cost-related unmet need. Factors that positively influence cost-related unmet need include older household heads, inpatient services, and urban residence. Education of household head, good self-rated health, larger household size, insured households, and higher wealth quintiles are negatively associated with cost-related unmet need.

Conclusion

The findings underscore the important role of cost in enabling access to healthcare services. The county level is seen to have a significant influence on cost-related unmet need. The variations noted in cost-related unmet need across the counties signify the existence of wide disparities within and between counties. Scaling up of health financing mechanisms would fundamentally require a multi-layered approach with a focus on the relatively poor counties to address the variations in access. Further segmentation of the population for better targeting of health financing policies is paramount, to address equity in access for the most vulnerable and marginalized populations.

Policy levers and priority-setting in universal health coverage: a qualitative analysis of healthcare financing agenda setting in Kenya

BACKGROUND

Competing priorities in health systems necessitate difficult choices on which health actions and investments to fund: decisions that are complex, value-based, and highly political. In light of the centrality of universal health coverage (UHC) in driving current health policy, we sought to examine the value interests that influence agenda setting in the country's health financing space. Given the plurality of Kenya's health policy levers, we aimed to examine how the perspectives of stakeholders involved in policy decision-making and implementation shape discussions on health financing within the UHC framework.

METHODS

A series of in-depth key informant interviews were conducted at national and county level (n = 13) between April and May 2018. Final thematic analysis using the Framework Method was conducted to identify similarities and differences amongst stakeholders on the challenges hindering Kenya's achievement of UHC in terms of its the optimisation of health service coverage; expansion of the population that benefits from essential healthcare services; and the minimisation of out-of-pocket costs associated with health-seeking behaviour.

RESULTS

Our findings indicate that the perceived lack of strategic leadership from Kenya's national government has led to a lack of agreement on stakeholders' interpretation of what is to be understood by UHC, its contextual values and priorities. We observe material differences between and within policy networks on the country's priorities for population coverage, healthcare service provision, and cost-sharing under the UHC dispensation. In spite of this, we note that progressive universalism is considered as the preferred approach towards UHC in Kenya, with most interviewees prioritising an equity-based approach that prioritises better access to healthcare services and financial risk protection. However, the conflicting priorities of key stakeholders risk derailing progress towards the expansion of access to health services and financial risk protection.

CONCLUSIONS

This study adds to existing knowledge of UHC in Kenya by contextualising the competing and evolving priorities that should be taken into consideration as the country strategises over its UHC process. We suggest that clear policy action is required from national government and county governments in order to develop a logical and consistent approach towards UHC in Kenya.

Limited alignment of publicly competitive disease funding with disease burden in Japan

OBJECTIVE

The need to align investments in health research and development (R&D) with public health needs is one of the most important public health challenges in Japan. We examined the alignment of disease-specific publicly competitive R&D funding to the disease burden in the country.

METHODS

We analyzed publicly available data on competitive public funding for health in 2015 and 2016 and compared it to disability-adjusted life year (DALYs) in 2016, which were obtained from the Global Burden of Disease (GBD) 2017 study. Their alignment was assessed as a percentage distribution among 22 GBD disease groups. Funding was allocated to the 22 disease groups based on natural language processing, using textual information such as project title and abstract for each research project, while considering for the frequency of information.

RESULTS

Total publicly competitive funding in health R&D in 2015 and 2016 reached 344.1 billion JPY (about 3.0 billion USD) for 32,204 awarded projects. About 49.5% of the funding was classifiable for disease-specific projects. Five GDB disease groups were significantly and relatively well-funded compared to their contributions to Japan's DALY, including neglected tropical diseases and malaria (funding vs DALY = 1.7% vs 0.0%, p<0.01) and neoplasms (28.5% vs 19.2%, p<0.001). In contrast, four GDB disease groups were significantly under-funded, including cardiovascular diseases (8.0% vs 14.8%, p<0.001) and musculoskeletal disorders (1.0% vs 11.9%, p<0.001). These percentages do not include unclassifiable funding.

CONCLUSIONS

While caution is necessary as this study was not able to consider public in-house funding and the methodological uncertainties could not be ruled out, the analysis may provide a snapshot of the limited alignment between publicly competitive disease-specific funding and the disease burden in the country. The results call for greater management over the allocation of scarce resources on health R&D. DALYs will serve as a crucial, but not the only, consideration in aligning Japan's research priorities with the public health needs. In addition, the algorithms for natural language processing used in this study require continued efforts to improve accuracy.

Socio-economic inequality and inequity in use of health care services in Kenya: evidence from the fourth Kenya household health expenditure and utilization survey

Background

Kenya is experiencing persistently high levels of inequity in health and access to care services. In 2018, decades of sustained policy efforts to promote equitable, affordable and quality health services have culminated in the launch of a universal health coverage scheme, initially piloted in four Kenyan counties and planned for national rollout by 2022. Our study aims to contribute to monitoring and evaluation efforts alongside policy implementation, by establishing a detailed, baseline assessment of socio-economic inequality and inequity in health care utilization in Kenya shortly before the policy launch.

Methods

We use concentration curves and corrected concentration indexes to measure socio-economic inequality in care use and the horizontal inequity index as a measure of inequity in care utilization for three types of care services: outpatient care, inpatient care and preventive and promotive care. Further insights into the individual and household level characteristics that determine observed inequality are derived through decomposition analysis.

Results

We find significant inequality and inequity in the use of all types of care services favouring richer population groups, with particularly pronounced levels for preventive and inpatient care services. These are driven primarily by differences in living standards and educational achievement, while the region of residence is a key driver for inequality in preventive care use only. Pro-rich inequalities are particularly pronounced for care provided in privately owned facilities, while public providers serve a much larger share of individuals from lower socio-economic groups.

Conclusions

Through its focus on increasing affordability of care for all Kenyans, the newly launched universal health coverage scheme represents a crucial step towards reducing disparities in health care utilization. However in order to achieve equity in health and access to care such efforts must be paralleled by multi-sectoral approaches to address all key drivers of inequity: persistent poverty, disparities in living standards and educational achievement, as well as regional differences in availability and accessibility of care.

Characterizing the Spatial Determinants and Prevention of Malaria in Kenya

The United Nations' Sustainable Development Goal 3 is to ensure health and well-being for all at all ages with a specific target to end malaria by 2030. Aligned with this goal, the primary objective of this study is to determine the effectiveness of utilizing local spatial variations to uncover the statistical relationships between malaria incidence rate and environmental and behavioral factors across the counties of Kenya. Two data sources are used-Kenya Demographic and Health Surveys of 2000, 2005, 2010, and 2015, and the national Malaria Indicator Survey of 2015. The spatial analysis shows clustering of counties with high malaria incidence rate, or hot spots, in the Lake Victoria region and the east coastal area around Mombasa; there are significant clusters of counties with low incidence rate, or cold spot areas in Nairobi. We apply an analysis technique, geographically weighted regression, that helps to better model how environmental and social determinants are related to malaria incidence rate while accounting for the confounding effects of spatial non-stationarity. Some general patterns persist over the four years of observation. We establish that variables including rainfall, proximity to water, vegetation, and population density, show differential impacts on the incidence of malaria in Kenya. The El-Nino-southern oscillation (ENSO) event in 2015 was significant in driving up malaria in the southern region of Lake Victoria compared with prior time-periods. The applied spatial multivariate clustering analysis indicates the significance of social and behavioral survey responses. This study can help build a better spatially explicit predictive model for malaria in Kenya capturing the role and spatial distribution of environmental, social, behavioral, and other characteristics of the households.

The burden of child and maternal malnutrition and trends in its indicators in the states of India: the Global Burden of Disease Study 1990-2017

BACKGROUND

Malnutrition is a major contributor to disease burden in India. To inform subnational action, we aimed to assess the disease burden due to malnutrition and the trends in its indicators in every state of India in relation to Indian and global nutrition targets.

METHODS

We analysed the disease burden attributable to child and maternal malnutrition, and the trends in the malnutrition indicators from 1990 to 2017 in every state of India using all accessible data from multiple sources, as part of Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. The states were categorised into three groups using their Socio-demographic Index (SDI) calculated by GBD on the basis of per capita income, mean education, and fertility rate in women younger than 25 years. We projected the prevalence of malnutrition indicators for the states of India up to 2030 on the basis of the 1990-2017 trends for comparison with India National Nutrition Mission (NNM) 2022 and WHO and UNICEF 2030 targets.

FINDINGS

Malnutrition was the predominant risk factor for death in children younger than 5 years of age in every state of India in 2017, accounting for 68·2% (95% UI 65·8-70·7) of the total under-5 deaths, and the leading risk factor for health loss for all ages, responsible for 17·3% (16·3-18·2) of the total disability-adjusted life years (DALYs). The malnutrition DALY rate was much higher in the low SDI than in the middle SDI and high SDI state groups. This rate varied 6·8 times between the states in 2017, and was highest in the states of Uttar Pradesh, Bihar, Assam, and Rajasthan. The prevalence of low birthweight in India in 2017 was 21·4% (20·8-21·9), child stunting 39·3% (38·7-40·1), child wasting 15·7% (15·6-15·9), child underweight 32·7% (32·3-33·1), anaemia in children 59·7% (56·2-63·8), anaemia in women 15-49 years of age 54·4% (53·7-55·2), exclusive breastfeeding 53·3% (51·5-54·9), and child overweight 11·5% (8·5-14·9). If the trends estimated up to 2017 for the indicators in the NNM 2022 continue in India, there would be 8·9% excess prevalence for low birthweight, 9·6% for stunting, 4·8% for underweight, 11·7% for anaemia in children, and 13·8% for anaemia in women relative to the 2022 targets. For the additional indicators in the WHO and UNICEF 2030 targets, the trends up to 2017 would lead to 10·4% excess prevalence for wasting, 14·5% excess prevalence for overweight, and 10·7% less exclusive breastfeeding in 2030. The prevalence of malnutrition indicators, their rates of improvement, and the gaps between projected prevalence and targets vary substantially between the states.

INTERPRETATION

Malnutrition continues to be the leading risk factor for disease burden in India. It is encouraging that India has set ambitious targets to reduce malnutrition through NNM. The trends up to 2017 indicate that substantially higher rates of improvement will be needed for all malnutrition indicators in most states to achieve the Indian 2022 and the global 2030 targets. The state-specific findings in this report indicate the effort needed in each state, which will be useful in tracking and motivating further progress. Similar subnational analyses might be useful for other low-income and middle-income countries.

FUNDING

Bill & Melinda Gates Foundation; Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Feasibility assessment of invigorating grassrooTs primary healthcare for prevention and management of cardiometabolic diseases in resource-limited settings in China, Kenya, Nepal, Vietnam (the FAITH study): rationale and design

Background

Cardiometabolic diseases are the leading cause of death and disability in many low- and middle-income countries. As the already severe burden from these conditions continues to increase in low- and middle-income countries, cardiometabolic diseases introduce new and salient public health challenges to primary health care systems. In this mixed-method study, we aim to assess the capacity of grassroots primary health care facilities to deliver essential services for the prevention and control of cardiometabolic diseases. Built on this information, our goal is to propose evidence-based recommendations to promote a stronger primary health care system in resource-limited settings.

Methods

The study will be conducted in resource-limited settings in China, Kenya, Nepal, and Vietnam using a mixed-method approach that incorporates a literature review, surveys, and in-depth interviews. The literature, statistics, and document review will extract secondary data on the burden of cardiometabolic diseases in each country, the existing policies and interventions related to strengthening primary health care services, and improving care related to non-communicable disease prevention and control. We will also conduct primary data collection. In each country, ten grassroots primary health care facilities across representative urban-rural regions will be selected. Health care professionals and patients recruited from these facilities will be invited to participate in the facility assessment questionnaire and patients’ survey. Stakeholders – including patients, health care professionals, policymakers at the local, regional, and national levels, and local authorities – will be invited to participate in in-depth interviews. A standard protocol will be designed to allow for adaption and localization in data collection instruments and procedures within each country.

Discussion

With a special focus on the capacity of primary health care facilities in resource-limited settings in low- and middle-income countries, this study has the potential to add new evidence for policymakers and academia by identifying the most common and significant barriers primary health care services face in managing and preventing cardiometabolic diseases. With these findings, we will generate evidence-based recommendations on potential strategies that are feasible for resource-limited settings in combating the increasing challenges of cardiometabolic diseases.

Age distribution, trends, and forecasts of under-5 mortality in 31 sub-Saharan African countries: A modeling study

BACKGROUND

Despite the sharp decline in global under-5 deaths since 1990, uneven progress has been achieved across and within countries. In sub-Saharan Africa (SSA), the Millennium Development Goals (MDGs) for child mortality were met only by a few countries. Valid concerns exist as to whether the region would meet new Sustainable Development Goals (SDGs) for under-5 mortality. We therefore examine further sources of variation by assessing age patterns, trends, and forecasts of mortality rates.

METHODS AND FINDINGS

Data came from 106 nationally representative Demographic and Health Surveys (DHSs) with full birth histories from 31 SSA countries from 1990 to 2017 (a total of 524 country-years of data). We assessed the distribution of age at death through the following new demographic analyses. First, we used a direct method and full birth histories to estimate under-5 mortality rates (U5MRs) on a monthly basis. Second, we smoothed raw estimates of death rates by age and time by using a two-dimensional P-Spline approach. Third, a variant of the Lee-Carter (LC) model, designed for populations with limited data, was used to fit and forecast age profiles of mortality. We used mortality estimates from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) to adjust, validate, and minimize the risk of bias in survival, truncation, and recall in mortality estimation. Our mortality model revealed substantive declines of death rates at every age in most countries but with notable differences in the age patterns over time. U5MRs declined from 3.3% (annual rate of reduction [ARR] 0.1%) in Lesotho to 76.4% (ARR 5.2%) in Malawi, and the pace of decline was faster on average (ARR 3.2%) than that observed for infant (IMRs) (ARR 2.7%) and neonatal (NMRs) (ARR 2.0%) mortality rates. We predict that 5 countries (Kenya, Rwanda, Senegal, Tanzania, and Uganda) are on track to achieve the under-5 sustainable development target by 2030 (25 deaths per 1,000 live births), but only Rwanda and Tanzania would meet both the neonatal (12 deaths per 1,000 live births) and under-5 targets simultaneously. Our predicted NMRs and U5MRs were in line with those estimated by the UN IGME by 2030 and 2050 (they overlapped in 27/31 countries for NMRs and 22 for U5MRs) and by the Institute for Health Metrics and Evaluation (IHME) by 2030 (26/31 and 23/31, respectively). This study has a number of limitations, including poor data quality issues that reflected bias in the report of births and deaths, preventing reliable estimates and predictions from a few countries.

CONCLUSIONS

To our knowledge, this study is the first to combine full birth histories and mortality estimates from external reliable sources to model age patterns of under-5 mortality across time in SSA. We demonstrate that countries with a rapid pace of mortality reduction (ARR ≥ 3.2%) across ages would be more likely to achieve the SDG mortality targets. However, the lower pace of neonatal mortality reduction would prevent most countries from achieving those targets: 2 countries would reach them by 2030, 13 between 2030 and 2050, and 13 after 2050.

Effect of Novartis Access on availability and price of non-communicable disease medicines in Kenya: a cluster-randomised controlled trial

BACKGROUND

Novartis Access is a Novartis programme that offers a portfolio of non-communicable disease medicines at a wholesale price of US$1 per treatment per month in low-income and middle-income countries. We evaluated the effect of Novartis Access in Kenya, the first country to receive the programme.

METHODS

We did a cluster-randomised controlled trial in eight counties in Kenya. Counties (clusters) were randomly assigned to the intervention or the control group with a covariate-constrained randomisation procedure that maximised balance on a set of demographic and health variables. In intervention counties, public and non-profit health facilities were allowed to purchase Novartis Access medicines from the Mission for Essential Drugs and Supplies (MEDS). Data were collected from all facilities served by MEDS and a sample of households in study counties. Households were eligible if they had at least one adult patient who had been diagnosed and prescribed medicines for one of the non-communicable diseases targeted by the programme: hypertension, heart failure, dyslipidaemia, type 2 diabetes, asthma, or breast cancer. Primary outcomes were availability and price of portfolio medicines at health facilities, irrespective of brand; and availability of medicines at patient households. Impacts were estimated with intention-to-treat analysis. This trial is registered with ClinicalTrials.gov (NCT02773095).

FINDINGS

On March 8, 2016, we randomly assigned eight clusters to intervention (four clusters; 74 health facilities; 342 patients) or control (four clusters; 63 health facilities; 297 patients). 69 intervention and 58 control health facilities, and 306 intervention and 265 control patients were evaluated after a 15 month intervention period (last visit February 28, 2018). Novartis Access significantly increased the availability of amlodipine (adjusted odds ratio [aOR] 2·84, 95% CI 1·10 to 7·37; p=0·031) and metformin (aOR 4·78, 95% CI 1·44 to 15·86; p=0·011) at health facilities, but did not affect the availability of portfolio medicines overall (adjusted β [aβ] 0·05, 95% CI -0·01 to 0·10; p=0·096) or their price (aβ 0·48, 95% CI -1·12 to 0·72; p=0·500). The programme did not affect medicine availability at patient households (aOR 0·83, 95% CI 0·44 to 1·57; p=0·569).

INTERPRETATION

Novartis Access had little effect in its first year in Kenya. Access programmes operate within complex health systems and reducing the wholesale price of medicines might not always or immediately translate to improved patient access. The evidence generated by this study will inform Novartis's efforts to improve their programme going forward. The study also contributes to the public evidence base on strategies for improving access to medicines globally.

FUNDING

Sandoz International (a subsidiary of Novartis International).

Progress in sanitation among poor households in Kenya: evidence from demographic and health surveys

Background

An estimated 14% of Kenyans practice open defecation. Poverty has been associated with open defecation. Kenya aims to achieve 100% open defecation free status by 2030 in line with sustainable development goal number 6. Using data from 3 national household surveys, this study sought to explore progress made in attaining this at the household level with a focus on poor households.

Methods

Kenya demographic and health survey for 2003, 2008 and 2014 respectively were analysed. Descriptive analysis and bivariate logistic regression was done with open defecation status as the dependent variable. Independent variables were poverty status, place of residence, region where household was located, absence of farm animals, gender and educational level of household head.

Results

The most common sanitation method nationally is a pit latrine without a slab. This ranged from 35.9–37.9%. Open defecation was 16.2, 12.1 and 9.9% in 2003, 2008 and 2014 respectively. Among households practicing open defecation, 81.8, 86 and 96% were classified as poor in 2003, 2008 and 2014 respectively. Poverty, educational level of household head and residing in a rural area were the most significant predictors of open defecation. Odds ratio for poverty was 9.4 (7–12.6 95% CI), 9.4(6.6–13.5 95% CI) and 29.2 (23.3–36.8 95% CI) for 2003, 2008 and 2014 respectively. The majority of richest households transitioned from using a pit latrine with a slab in 2003 to using a flush toilet connected to a sewer in 2008 and 2014. The majority of richer households transitioned from using a pit latrine without a slab in 2003 and 2008 to using a pit latrine with a slab in 2014. The majority of middle and poorer households stagnated at using a pit latrine without a slab across the similar period. The poorest households stagnated at the open defecation stage.

Conclusion

The burden of open defecation has increased among poor households, more so among the poorest. This may be attributed to non-poor households exiting the open defecation stage at a higher rate compared to poor households. Poor households may need to be targeted more if Kenya is to attain open defecation free status by 2030.