The introduction of new policies and strategies to reduce inequities and improve child health in Kenya: A country case study on progress in child survival, 2000-2013

Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

A realist synthesis to develop an explanatory model of how policy instruments impact child and maternal health outcomes

BACKGROUND

Child and maternal health, a key marker of overall health system performance, is a policy priority area by the World Health Organization and the United Nations, including the Sustainable Development Goals. Previous realist work has linked child and maternal health outcomes to globalization, political tradition, and the welfare state. It is important to explore the role of other key policy-related factors. This paper presents a realist synthesis, categorising policy instruments according to the established NATO model, to develop an explanatory model of how policy instruments impact child and maternal health outcomes.

METHODS

A systematic literature search was conducted to identify studies assessing the relationships between policy instruments and child and maternal health outcomes. Data were analysed using a realist framework. The first stage of the realist analysis process was to generate micro-theoretical initial programme theories for use in the theory adjudication process. Proposed theories were then adjudicated iteratively to produce a set of final programme theories.

FINDINGS

From a total of 43,415 unique records, 632 records proceeded to full-text screening and 138 papers were included in the review. Evidence from 132 studies was available to address this research question. Studies were published from 1995 to 2021; 76% assessed a single country, and 81% analysed data at the ecological level. Eighty-eight initial candidate programme theories were generated. Following theory adjudication, five final programme theories were supported. According to the NATO model, these were related to treasure, organisation, authority-treasure, and treasure-organisation instrument types.

CONCLUSIONS

This paper presents a realist synthesis to develop an explanatory model of how policy instruments impact child and maternal health outcomes from a large, systematically identified international body of evidence. Five final programme theories were supported, showing how policy instruments play an important yet context-dependent role in influencing child and maternal health outcomes.

Progress towards achieving child survival goals in Kenya after devolution: Geospatial analysis with scenario-based projections, 2015-2025

Subnational projections of under-5 mortality (U5M) have increasingly become an essential planning tool to support Sustainable Development Goals (SDGs) agenda and strategies for improving child survival. To support child health policy, planning, and tracking child development goals in Kenya, we projected U5M at units of health decision making. County-specific annual U5M were estimated using a multivariable Bayesian space-time hierarchical model based on intervention coverage from four alternate intervention scale-up scenarios assuming 1) the highest subnational intervention coverage in 2014, 2) projected coverage based on the fastest county-specific rate of change observed in the period between 2003-2014 for each intervention, 3) the projected national coverage based on 2003-2014 trends and 4) the country-specific targets of intervention coverage relative to business as usual (BAU) scenario. We compared the percentage change in U5M based on the four scale-up scenarios relative to BAU and examined the likelihood of reaching SDG 3.2 target of at least 25 deaths/1,000 livebirths by 2022 and 2025. Projections based on 10 factors assuming BAU, showed marginal reductions in U5M across counties with all the counties except Mandera county not achieving the SDG 3.2 target by 2025. Further, substantial reductions in U5M would be achieved based on the various intervention scale-up scenarios, with 63.8% (30), 74.5% (35), 46.8% (22) and 61.7% (29) counties achieving SDG target for scenarios 1,2,3 and 4 respectively by 2025. Scenario 2 yielded the highest reductions of U5M with individual scale-up of access to improved water, recommended treatment of fever and accelerated HIV prevalence reduction showing considerable impact on U5M reduction (≥ 20%) relative to BAU. Our results indicate that sustaining an ambitious intervention scale-up strategy matching the fastest rate observed between 2003-2014 would substantially reduce U5M in Kenya. However, despite this ambitious scale-up scenario, 25% (12 of 47) of the Kenya's counties would still not achieve SDG 3.2 target by 2025.

Health beliefs and (timely) use of facility-based care for under-five children: lessons from the qualitative component of Nigeria's 2019 VASA

Background

Nigeria’s under-five health outcomes have improved over the years, but the mortality rates remain unacceptably high. The qualitative component of Nigeria’s 2019 verbal and social autopsy (VASA) showed that caregivers’ health beliefs about causes of illnesses and efficacious treatment options contribute to non-use/delay in use of facility-based healthcare for under-five children. This study explored how these health beliefs vary across zones and how they shape how caregivers seek healthcare for their under-five children.

Methods

Data for this study come from the qualitative component of the 2019 Nigeria VASA, comprising 69 interviews with caregivers of under-five children who died in the five-year period preceding the 2018 Nigeria Demographic and Health Survey (NDHS); and 24 key informants and 48 focus group discussions (FGDs) in 12 states, two from each of the six geo-political zones. The transcripts were coded using predetermined themes on health beliefs from the 2019 VASA (qualitative component) using NVivo.

Results

The study documented zonal variation in belief in traditional medicine, biomedicine, spiritual causation of illnesses, syncretism, and fatalism, with greater prevalence of beliefs discouraging use of facility-based healthcare in the southern zones. Driven by these beliefs and factors such as availability, affordability, and access to and perceived quality of care in health facilities, caregivers often choose one or a combination of traditional medicines, care from medicine vendors, and faith healing. Most use facility-based care as the last option when other methods fail.

Conclusion

Caregivers’ health beliefs vary by zones, and these beliefs influence when and whether they will use facility-based healthcare services for their under-five children. In Nigeria’s northern zones, health beliefs are less likely to deter caregivers from using facility-based healthcare services, but they face other barriers to accessing facility-based care. Interventions seeking to reduce under-five deaths in Nigeria need to consider subnational differences in caregivers’ health beliefs and the healthcare options they choose based on those beliefs.

Background predictors of time to death in infancy: evidence from a survival analysis of the 2018 Nigeria DHS data

Background

Nigeria’s child health profile is quite concerning with an infant mortality rate of 67 deaths per 1000 live births and a significant slowing down in progress towards improving child health outcomes. Nigeria’s 2018 Demographic and Health Survey (DHS) suggests several bio-demographic risk factors for child death, including mother’s poor education, poverty, sex of child, age of mother, and location (rural vs urban) but studies are yet to explore the predictive power of these variables on infant survival in Nigeria.

Methods

The study extracted data for all births in the last 12 months preceding the 2018 Nigeria DHS and used the Cox proportional hazard model to predict infant survival in Nigeria. Failure in this analysis is death with two possible outcomes – dead/alive – while the survival time variable is age at death. We censored infants who were alive at the time of the study on the day of the interview. Covariates in the analysis were: age of mother, education of mother, wealth quintile, sex of child, location, region, place of delivery, and age of pregnancy.

Results

The study found that a higher education of a mother compared to no education (β = .429; p-value < 0.05); belonging to a household in the richer wealth quintile (β = .618; p-value < 0.05) or the highest quintile (β = .553; p-value < 0.05), compared to the lowest wealth quintile; and living in North West (β = 1.418; p-value < 0.05) or South East zone (β = 1.711; p-value < 0.05), significantly predict infant survival.

Conclusion

Addressing Nigeria’s infant survival problem requires interventions that give attention to the key drivers – education, socio-economic status, and socio-cultural contextual issues. We therefore recommend full implementation of the universal basic education policy, and child health education programs targeted at mothers as long- and short-term solutions to the problem of poor child health outcomes in Nigeria. We also argue in favor of better use of evidence in policy and program development in Nigeria.

"You can't even ask a question about your child": Examining experiences of parents or caregivers during hospitalization of their sick young children in Kenya: A qualitative study

Background

Globally, about 5.2 million children under the age of five died in 2019, and more than half of those deaths occurred in Sub-Saharan Africa. In almost every death of a sick child, there is a parent/caregiver seeking health services for their child. This study sought to understand the experiences of care for parents/caregivers (caregivers) as they navigate the hospital system with the aim of identifying opportunities to improve service delivery and child health outcomes.

Methods

Qualitative data were collected from five hospitals in Kenya: three in Nairobi County and two in Bungoma County. Twenty-five in-depth interviews with caregivers (couples and single women) of young children 0-24 months old, 17 focus group discussions with women and men, and 64 institutional ethnographic observations were completed. Data were analyzed by initial annotation of transcripts and field materials, followed by open coding and thematic analysis using Nvivo 12 software. Summary themes were used to compare experiences between female and male caregivers, their child's age group, and study sites.

Results

Caregivers faced complex processes of care while seeking health services for their sick young children. Three overarching themes emerged with some variability across female and male caregiver perspectives: (1) Navigating structural issues: long wait times, confusing payment mechanisms, overcrowding, unhygienic conditions, and strict visitation policies; (2) Interactions with providers: positive experiences, including providers showing empathy and concern, and negative experiences of harsh language, neglect, lack of privacy, discounting caregiver perspectives, and not involving men; Limited communication between caregivers and providers on child's diagnosis, treatment, and progress and lack of communication specifically between male caregivers and providers; and (3) Limited emotional support for both caregivers during difficult diagnosis or bereavement.

Conclusions

To improve experiences, interventions, programs, and policies need to focus on good provider-caregiver partnerships; enhancing opportunities for male engagement, such as supportive visiting hours; effective communication between caregivers and providers; access to adequate emotional support; and an enabling hospital environment.

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.

Critical Interpretive Synthesis of Qualitative Data on the Health Care Ecosystem for Vulnerable Newborns in Low- to Middle-Income Countries

OBJECTIVE

To critically assess and synthesize qualitative findings regarding the health care ecosystem for vulnerable (low-birth-weight or sick) neonates in low- to middle-income countries (LMICs).

DATA SOURCES

Between May 4 and June 2, 2020, we searched four databases (Medline [PubMed], SCOPUS, PsycINFO, and Web of Science) for articles published from 2010 to 2020. Inclusion criteria were peer-reviewed reports of original studies focused on the health care ecosystem for vulnerable neonates in LMICs. We also searched the websites of several international development agencies and included findings from primary data collected between May and July 2019 at a tertiary hospital in Kenya. We excluded studies and reports if the focus was on healthy neonates or high-income countries and if they contained only quantitative data, were written in a language other than English, or were published before 2010.

STUDY SELECTION

One of the primary authors conducted an initial review of titles and abstracts (n = 102) and excluded studies that were not consistent with the purpose of the review (n = 60). The two primary authors used a qualitative appraisal checklist to assess the validity of the remaining studies (n = 42) and reached agreement on the final 13 articles.

DATA EXTRACTION

The two primary authors independently conducted open and axial coding of the data. We incorporated data from studies with different units of analysis, types of methodology, research topics, participant types, and analytical frameworks in an emergent conceptual development process according to the critical interpretive synthesis methodology.

DATA SYNTHESIS

We synthesized our findings into one overarching theme, Pervasive Turbulence Is a Defining Characteristic of the Health Care Ecosystem in LMICs, and two subthemes: Pervasive Turbulence May Cause Tension Between the Setting and the Caregiver and Pervasive Turbulence May Result in a Loss of Synergy in the Caregiver-Parent Relationship.

CONCLUSION

Because pervasive turbulence characterizes the health care ecosystems in LMICs, interventions are needed to support the caregiver-parent interaction to mitigate the effects of tension in the setting.

Utilization of Routine Health Information from Health Management Information System and Associated Factors Among Health Workers at Health Centers in Oromia Special Zone, Ethiopia: A Multilevel Analysis

Introduction

Health management information system is a building block for the health system. Even if using health facility data at all levels is critical, it is poorly practiced in developing countries. There is limited evidence about the utilization of routine health information from the health management information system in the study area. This study aimed to assess the utilization of routine health information from health management information system and associated factors among health professionals at health centers in Oromia special zone, Amhara region, Ethiopia.

Methods

A facility-based cross-sectional study was conducted from February to March 2019. A total of 369 health professionals who were the focal person for each service delivery point were taken from the selected health centers. The data analysis was done using STATA version 14. A multilevel mixed-effect logistic regression model was carried out to identify factors associated with utilization of routine health information from the health management information system. Adjusted odds ratio with 95% CI was reported to show the strength of association. A P-value of <0.05 was used to declare statistical significance.

Results

The magnitude of good routine health information utilization among health care professionals was 52.8%. Training (AOR=2.40, 95% CI=1.35, 4.26), availability of standard indicator definition (AOR=2.01, 95% CI=1.13, 3.57), data analysis skills (AOR=2.59, 95% CI=1.45, 4.62), regular feedback (AOR=2.29, 95% CI=1.29, 4.05), performance evaluation (AOR=2.60, 95% CI=1.19, 5.68) and timely reporting (AOR=2.89, 95% CI=1.54, 5.42) were significantly associated with routine health information utilization.

Conclusion

The overall utilization of routine health information from the health management information system was low. Therefore, the Zone health department and woreda health offices need to give training on HMIS data use, and avail standard indicator definition for all health care workers at all service delivery points.

Measuring child survival for the Millennium Development Goals in Africa: what have we learned and what more is needed to evaluate the Sustainable Development Goals?

Reducing child mortality is a key global health challenge. We examined reasons for greater or lesser success in meeting under-five mortality rate reductions, i.e. Millennium Development Goal #4, between 1990 and 2015 in Sub-Saharan Africa where child mortality remains high. We first examined factors associated with child mortality from all World Health Organization African Region nations during the Millennium Development Goal period. This analysis was followed by case studies of the facilitators and barriers to Millennium Development Goal #4 in four countries – Kenya, Liberia, Zambia, and Zimbabwe. Quantitative indicators, policy documents, and qualitative interviews and focus groups were collected from each country to examine factors within and across countries related to child mortality. We found familiar themes that highlighted the need for both specific services (e.g. primary care access, emergency obstetric and neonatal care) and general management (e.g. strong health governance and leadership, increasing community health workers, quality of care). We also identified methodological opportunities and challenges to assessing progress in child health, which can provide insights to similar efforts during the Sustainable Development Goal period. Specifically, it is important for countries to adapt general international goals and measurements to their national context, considering baseline mortality rates and health information systems, to develop country-specific goals. It will also be critical to develop more rigorous measurement tools and indicators to accurately characterize maternal, neonatal, and child health systems, particularly in the area of governance and leadership. Valuable lessons can be learned from Millennium Development Goal successes and failures, as well as how they are evaluated. As countries seek to lower child mortality further during the Sustainable Development Goal period, it will be necessary to prioritize and support countries in quantitative and qualitative data collection to assess and contextualize progress, identifying areas needing improvement.

Determinants of early sexual initiation among female youth in Ethiopia: a multilevel analysis of 2016 Ethiopian Demographic and Health Survey

Background

Evidences on determinants of early sexual initiation among female youth is still limited especially; community-level factors are not investigated in Ethiopia. Therefore, the aim of this study was to assess individual and community-level factors associated with early sexual initiation among female youth in Ethiopia.

Methods

The 2016 Ethiopian Demographic and Health Survey (EDHS) dataset were used and a total of 6143 participants (female youth) were included. Multi-level mixed-effect logistic regression was done to identify individual and community-level factors. Adjusted odds ratio along with 95% confidence interval was used to show the strength and direction of the association. Finally, the level of statistical significance was declared at P value less than 0.05.

Results

Individual-level factors significantly associated with early sexual initiation among female youth were; age group from 19 to 24 years [AOR = 5.8, 95% CI = (4.6, 7.3)], not attending school [AOR = 14.1, 95% CI = (8.1, 24.7)], ever chewing Chat [AOR = 2.0, 95% CI = (1.3, 3.0)]. From community-level factors: living in Addis Ababa [AOR = 0.3, 95% CI = (0.2, 0.5)], living in Gambella [AOR = 2.7, 95% CI = (1.7, 4.3)] and live in a low proportion of poor communities [AOR = 0.7, 95% CI = (0.5, 0.9)] were significantly associated with early sexual initiation among female youth in Ethiopia.

Conclusions

Age, low educational status, ever chewing Chat, region and live in a high proportion of poor community had a statistical association with early sexual initiation among female youth in Ethiopia. Improving educational coverage and community-level of wealth status are important intervention areas to delay the age of early sexual initiation.

Promoting progress in child survival across four African countries: the role of strong health governance and leadership in maternal, neonatal and child health

Despite numerous international and national efforts, only 12 countries in the World Health Organization's African Region met the Millennium Development Goal #4 (MDG#4) to reduce under-five mortality by two-thirds by 2015. Given the variability across sub-Saharan Africa, a four-country study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia and Zambia were chosen to represent countries making substantial progress towards MDG#4, while Kenya and Zimbabwe represented countries making less progress. Our individual case studies suggested that strong health governance and leadership (HGL) was a significant driver of the greater success in Liberia and Zambia compared with Kenya and Zimbabwe. To elucidate specific components of national HGL that may have substantially influenced the pace of reductions in child mortality, we conducted a cross-country analysis of national policies and strategies pertaining to maternal, neonatal and child health (MNCH) and qualitative interviews with individuals working in MNCH in each of the four study countries. The three aspects of HGL identified in this study which most consistently contributed to the different progress towards MDG#4 among the four study countries were (1) establishing child survival as a top national priority backed by a comprehensive policy and strategy framework and sufficient human, financial and material resources; (2) bringing together donors, strategic partners, health and non-health stakeholders and beneficiaries to collaborate in strategic planning, decision-making, resource-allocation and coordination of services; and (3) maintaining accountability through a 'monitor-review-act' approach to improve MNCH. Although child mortality in sub-Saharan Africa remains high, this comparative study suggests key health leadership and governance factors that can facilitate reduction of child mortality and may prove useful in tackling current Sustainable Development Goals.

Factors influencing rapid progress in child health in post-conflict Liberia: a mixed methods country case study on progress in child survival, 2000-2013

OBJECTIVES

Only 12 countries in the WHO's African region met Millennium Development Goal 4 (MDG 4) to reduce under-five mortality by two-thirds by 2015. Given the variability across the African region, a four-country mixed methods study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia was selected for an in-depth case study due to its success in reducing under-five mortality by 73% and thus successfully meeting MDG 4. Liberia's success was particularly notable given the civil war that ended in 2003. We examined some factors contributing to their reductions in under-five mortality.

DESIGN

A case study mixed methods approach drawing on data from quantitative indicators, national documents and qualitative interviews was used to describe factors that enabled Liberia to rebuild their maternal, neonatal and child health (MNCH) programmes and reduce under-five mortality following the country's civil war.

SETTING

The interviews were conducted in Monrovia (Montserrado County) and the areas in and around Gbarnga, Liberia (Bong County, North Central region).

PARTICIPANTS

Key informant interviews were conducted with Ministry of Health officials, donor organisations, community-based organisations involved in MNCH and healthcare workers. Focus group discussions were conducted with women who have experience accessing MNCH services.

RESULTS

Three prominent factors contributed to the reduction in under-five mortality: national prioritisation of MNCH after the civil war; implementation of integrated packages of services that expanded access to key interventions and promoted intersectoral collaborations; and use of outreach campaigns, community health workers and trained traditional midwives to expand access to care and improve referrals.

CONCLUSIONS

Although Liberia experiences continued challenges related to limited resources, Liberia's effective strategies and rapid progress may provide insights for reducing under-five mortality in other post-conflict settings.

What is the availability of services for paediatric ENT surgery and paediatric surgery in Africa?

BACKGROUND

Children constitute 50% of Africa's population. Sub-Saharan Africa has the highest under-five mortality rates in the world. This study is the first to document the availability of paediatric ENT and paediatric surgery services in Africa.

OBJECTIVE

To determine the availability of paediatric ENT services in Africa, as well as that of paediatric surgery that would complement paediatric ENT.

METHOD

A descriptive observational study in the form of an online questionnaire was distributed by email to known ENT and paediatric surgeons based in Africa.

RESULTS

Surgeons from twelve of 23 African countries responded to the survey. Seven countries had both ENT and paediatric surgery responses. In 8 of the 11 countries, the number of ENT surgeons per country was<6% of that of the UK, with 1 ENT surgeon per 414,000 people and 1 paediatric surgeon per 1,181,151 people. Ten of 11 countries reported hearing assessments in schools were poor/unavailable. Seventy-three percent responded positively for access to rigid laryngoscopes, bronchoscopes, cameras and fibre optic cables, tracheostomy, anaesthesia and nurse practitioners. Access was reported as poor/unavailable for balloon dilators 73% (8/11 countries); CPAP machines 73% (8/11) and sleep studies 82% (9/11 countries). Flexible endoscopes were available in 50% (4/8 countries), 75% (6/8 countries) had access to a camera, monitor and stack. Thirty-eight percent (3/9 countries) reported no ENT specialists with paediatric training.

CONCLUSIONS

There is a great shortage of paediatric ENT and paediatric surgery services in Africa. More regional training opportunities and health infrastructure for these surgical specialties are needed. Collaborative development of paediatric ENT, surgery and anaesthesia should be considered to improve ENT-related child health in Africa.

Estimating the need for inpatient neonatal services: an iterative approach employing evidence and expert consensus to guide local policy in Kenya

Universal access to quality newborn health services will be essential to meeting specific Sustainable Development Goals to reduce neonatal and overall child mortality. Data for decision making are crucial for planning services and monitoring progress in these endeavours. However, gaps in local population-level and facility-based data hinder estimation of health service requirements for effective planning in many low-income and middle-income settings.

We worked with local policy makers and experts in Nairobi City County, an area with a population of four million and the highest neonatal mortality rate amongst counties in Kenya, to address this gap, and developed a systematic approach to use available data to support policy and planning. We developed a framework to identify major neonatal conditions likely to require inpatient neonatal care and identified estimates of incidence through literature review and expert consultation, to give an overall estimate for the year 2017 of the need for inpatient neonatal care, taking account of potential comorbidities.

Our estimates suggest that almost 1 in 5 newborns (183/1000 live births) in Nairobi City County may need inpatient care, resulting in an estimated 24 161 newborns expected to require care in 2017. Our approach has been well received by local experts, who showed a willingness to work together and engage in the use of evidence in healthcare planning. The process highlighted the need for co-ordinated thinking on admission policy and referral care especially in a pluralistic provider environment helping build further appetite for data-informed decision making.