Accelerating Kenya's progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015

The temporal and spatial interpretation of China's health financing: what do Chinese' government 'do' in new healthcare reform?

OBJECTIVE

The analysis of health expenditure and its structure takes on a critical significance in national health policy research, and the public welfare of national health undertakings can be manifested by the government's investment in health. In this study, the aim was to analyze total health care costs, the structure of health financing, and the government's investment in health, so as to provide a reference for China's health policy adjustment.

METHODS

Description and cluster analysis were conducted using R language to analyze total health care costs and the structure of health financing of 31 regions in China between 1990 and 2020 to gain insights into the temporal and spatial changes total health care costs and the structure of health financing in China. The government's investment in health was analyzed using description and abundance heatmap to know the temporal and spatial changes of the government's health investment.

RESULTS

The total health expenditure per capita reached 5112.3 yuan in 2020, and the total health expenditure accounted for 7.10% of GDP. The government health expenditure took up a significantly lower share of the total health expenditure in 1993-2006 (17.09% [16.30,17.88]), whereas it has been nearly 30% (29.56% [28.73,30.3]) over the past few years. As to 31 regions in China, the government health expenditure per total health expenditure reached 67.94% in Tibet, whereas a level of 27.866% (25.629-30.103) were maintained in other regions. Beijing and Shanghai have achieved over 50.00% of social health expenditure per total health expenditure in recent five years, it was significantly higher than other regions. The per capita government expenditure as a fraction of GDP of Tibet (6.842%) was the highest region in 2011-2019, while Jiangsu (only 0.937%) was the lowest region.

CONCLUSIONS

Sustainable increases in total health expenditure as a percent of GDP take on a critical significance to adequate health financing. Equity in health financing has been insufficient in China, and spatial and temporal differences of China's health financing structure are significant. The region' governments should adjust policy based on typical regions to weaken the differences.

Does a free maternity policy in Kenya work? Impact and cost-benefit consideration based on demographic health survey data

This paper evaluates the overall effect of the Kenyan free maternity policy (FMP) on the main outcomes (early neonatal and neonatal deaths) and intermediate outcomes (delivery through Caesarean Section (CS), skilled birth attendance (SBA), birth in a public hospital and low birth weight (LBW)) using the 2014 Demographic Health Survey. We applied the difference-in-difference (DID) approach to compare births (to the same mothers) happening before and after the start of the policy (June 2013) and a limited cost-benefit analysis (CBA) to assess the net social benefit of the FMP. The probabilities of birth resulting in early neonatal and neonatal mortality are significantly reduced by 17-21% and 19-20%, respectively, after the FMP introduction. The probability of birth happening through CS reduced by 1.7% after implementing the FMP, while that of LBW birth is increased by 3.7% though not statistically significant. SBA and birth in a public facility did not moderate the policy's effects on early neonatal mortality, neonatal mortality, and delivery through CS. They were not significant determinants of the policy effects on the outcomes. There is a significant causal impact of the FMP in reducing the probability of early neonatal and neonatal mortality, but not the delivery through CS. The FMP cost-to-benefit ratio was 21.22, and there were on average 4015 fewer neonatal deaths in 2013/2014 due to the FMP. The net benefits are higher than the costs; thus, there is a need to expand and sustainably fund the FMP to avert more neonatal deaths potentially.

The burden of Hepatitis B virus infection in Kenya: A systematic review and meta-analysis

Background

Chronic Hepatitis B virus (HBV) infection causes liver cirrhosis and cancer and is a major public health concern in Kenya. However, so far no systematic review and meta-analysis has been conducted to estimate the burden of disease in the country. A better understanding of HBV infection prevalence will help the government implement efficient strategies at eliminating the disease. This systematic review and meta-analysis was therefore conducted to summarize and update the available information on the burden of HBV in Kenya.

Method

We systematically searched PubMed, Science Direct, Web of Science, Scopus, African Journals OnLine, and Google Scholar databases to retrieve primary studies conducted between January 1990 and June 2021 that assessed the prevalence of HBV infection in Kenya based on measurement of the Hepatitis B Surface Antigen (HBsAg). Meta-analysis was performed using the random effects model where HBsAg prevalence was estimated at a 95% confidence interval (CI) after simple pooling analysis. Potential sources of heterogeneity were also investigated.

Results

Fifty studies were included in the meta-analysis with a sample size of 108448. The overall pooled prevalence estimate of HBV in Kenya was 7.8% (95% CI: 5.8-10.1). Subgroup analysis revealed the highest prevalence among patients presenting with jaundice at 41.7% (95% CI: 13.5-73.3) whereas blood donors had the lowest prevalence at 4.1% (95% CI: 2.4-6.3). Prevalence in Human Immunodeficiency Virus (HIV)-infected individuals was 8.2% (95% CI: 5.8-11.0). An estimate of the total variation between studies revealed substantial heterogeneity (I² = 99%) which could be explained by the study type, the risk status of individuals, and the region of study.

Conclusion

We present the first systematic review and meta-analysis of the prevalence of HBV in Kenya. Our results show that the burden of HBV in Kenya is still enormous. This calls for an urgent need to implement public health intervention measures and strategic policies that will bring the disease under control and lead to final elimination.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=264859, identifier: CRD42021264859.

Traditional Medicine Beliefs and Practices among Caregivers of Children under Five Years-The Child Health and Mortality Prevention Surveillance (CHAMPS), Western Kenya: A qualitative study

BACKGROUND

Approximately 80% of the population residing in sub-Saharan Africa relies on Traditional Medicine (TM). However, literature on factors motivating the use of TM for children under the age of five in these settings is limited. Such information can guide policy formulation for integration of TM into mainstream health care services. This study aimed to describe the motivation on use of TM among caregivers of children residing in rural and urban communities in western Kenya.

METHODS

The socio-behavioral sciences (SBS) arm of the Child Health and Mortality Prevention Surveillance (CHAMPS) program in western Kenya, conducted a cross-sectional qualitative study in Manyatta-an urban informal settlement located in Kisumu town and Karemo-a rural setting in Siaya County. We performed 29 in-depth interviews, 5 focus group discussions and 11 semi-structured interviews with community representatives (n = 53), health workers (n = 17), and community leaders (n = 18). All the participants were purposively sampled. We performed thematic analysis using both inductive and deductive approaches. Data management was completed on Nvivo 11.0 software (QSR International, Melbourne, Australia).

RESULTS

Our findings reveal that some caregivers prefer TM to treat some childhood diseases. Use of TM was informed by illness beliefs about etiology of disease. We observed an appreciation from the study participants that malaria can effectively be treated by Conventional Medicine (CM) while TM was preferred to treat measles and diseases believed to be associated with supernatural etiology such as witchcraft, evil spirit or breaching cultural taboos. TM was also used in instances where CM failed to provide a diagnosis or when CM was 'slow'. TM in such cases was used as a last resort.

CONCLUSION

We observed varied beliefs that motivate caregivers' choice of TM use among children in western Kenya. It is therefore crucial to consider perceptions and socio-cultural beliefs about illnesses when formulating interventions that are geared towards child health.

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.

Cause and risk factors of early neonatal death in Ethiopia

Background

Globally, three fourth of neonatal deaths occur during the early neonatal period, this makes it a critical time to reduce the burden of neonatal death. The survival status of a newborn is determined by the individual (neonatal and maternal), and facility-level factors. Several studies were conducted in Ethiopia to assess early neonatal death; however, most of the studies had limited participants and did not well address the two main determinant factors covered in this study. In response to this gap, this study attempted to examine factors related to early neonatal death based on perinatal death surveillance data in consideration of all the possible determinants of early neonatal death.

Methods

The national perinatal death surveillance data were used for this study. A total of 3814 reviewed perinatal deaths were included in the study. Bayesian multilevel parametric survival analysis was employed to identify factors affecting the survival of newborns during the early neonatal period. Adjusted time ratio (ATR) with 95% Bayesian credible intervals (CrI) was reported and log-likelihood was used for model comparison. Statistical significance was declared based on the non-inclusion of 1.0 in the 95% CrI.

Result

More than half (52.4%) of early neonatal deaths occurred within the first two days of birth. Per the final model, as gestational age increases by a week the risk of dying during the early neonatal period is reduced by 6% [ATR = 0.94,95%CrI:(0.93–0.96)]. There was an increased risk of death during the early neonatal period among neonates deceased due to birth injury as compared to neonates who died due to infection [ATR = 2.05,95%CrI:(1.30–3.32)]; however, perinates who died due to complication of an intrapartum event had a lower risk of death than perinates who died due to infection [ATR = 0.87,95%CrI:(0.83–0.90)]. As the score of delay one and delay three increases by one unit, the newborn’s likelihood of surviving during the early neonatal period is reduced by 4% [ATR = 1.04,95%CrI:(1.01–1.07)] and 21% [ATR = 1.21,95%CrI:(1.15–1.27)] respectively. Neonates born from mothers living in a rural area had a higher risk of dying during the early neonatal period than their counterparts living in an urban area [ATR = 3.53,95%CrI:(3.34–3.69)]. As compared to neonates treated in a primary health facility, being treated in secondary [ATR = 1.14,95%CrI:(1.02–1.27)] and tertiary level of care [ATR = 1.15,95%CrI:(1.04–1.25)] results in a higher risk of death during the early neonatal period.

Conclusion

The survival of a newborn during the early neonatal period is determined by both individual (gestational age, cause of death, and delay one) and facility (residence, type of health facility and delay three) level factors. Thus, to have a positive early neonatal outcome, a tailored intervention is needed for the three major causes of death (i.e Infection, birth injury, and complications of the intrapartum period). Furthermore, promoting maternal health, improving the health-seeking behaviour of mothers, strengthening facility readiness, and narrowing down inequalities in service provision are recommended to improve the newborn’s outcomes during the early neonatal period.

Facilitation as a component of evidence implementation: a multinational perspective

BACKGROUND

Facilitation is a key component of JBI's approach to evidence implementation along with context analysis and evaluation of process and outcomes. Although the role of facilitation is recognized as a critical component of evidence implementation, what constitutes effective facilitation is poorly understood.

AIM

This article presents a descriptive exploration of facilitation as it occurs in evidence implementation initiatives conducted in various healthcare and geographical contexts. All projects used the JBI approach to evidence implementation.

METHODS

To provide a multinational perspective on how facilitation was operationalized to promote positive changes in clinical practice and health outcomes, five case studies of evidence implementation projects are presented.

RESULTS

The cases highlighted that facilitation is a multifaceted process that can be met through a variety of roles that address aspects of education and capacity building, partnerships, action planning, problem solving and evaluation. Facilitation in all cases appeared to be collaborative, with multiple 'players' within and outside of the health organization being involved in the process. Although there are similarities in activities, facilitation involved some level of local contextualization where there were unique or additional activities performed to accommodate the local needs and requirements of the health organization involved in each case. Numerous contextual factors influenced the success of the implementation initiative.

CONCLUSION

The cases emphasized the complex nature of facilitation as a strategy for evidence implementation, indicating that contextual attributes and features define the range of knowledge, skills, and activities that should take place in order for facilitation to be effective. Although there appears to be some core components, tailoring and adaptation of the facilitation process (or roles) is required.

Trust, Care Avoidance, and Care Experiences among Kenyan Women Who Delivered during the COVID-19 Pandemic

We explore how the COVID-19 pandemic was associated with avoidance of, and challenges with, antenatal, childbirth and postpartum care among women in Kiambu and Nairobi counties, Kenya; and whether this was associated with a report of declined trust in the health system due to the pandemic. Women who delivered between March and November 2020 were invited to participate in a phone survey about their care experiences (n = 1122 respondents). We explored associations between reduced trust and care avoidance, delays and challenges with healthcare seeking, using logistic regression models adjusted for women's characteristics. Approximately half of respondents said their trust in the health care system had declined due to COVID-19 (52.7%, n = 591). Declined trust was associated with higher likelihood of reporting barriers accessing antenatal care (aOR 1.59 [95% CI 1.24, 2.05]), avoiding care for oneself (aOR 2.26 [95% CI 1.59, 3.22]) and for one's infant (aOR 1.77 [95% CI 1.11, 2.83]), and of feeling unsafe accessing care (aOR 1.52 [95% CI 1.19, 1.93]). Since March 2020, emergency services, routine care and immunizations were avoided most often. Primary reported reasons for avoiding care and challenges accessing care were financial barriers and problems accessing the facility. Declined trust in the health care system due to COVID-19 may have affected health care-seeking for women and their children in Kenya, which could have important implications for their health and well-being. Programs and policies should consider targeted special "catch-up" strategies that include trust-building messages and actions for women who deliver during emergencies like the COVID-19 pandemic.

Joint spatio-temporal modelling of adverse pregnancy outcomes sharing common risk factors at sub-county level in Kenya, 2016-2019

Background

Adverse pregnancy outcomes jointly account for a high proportion of mortality and morbidity among pregnant women and their infants. Furthermore, the burden attributed to adverse pregnancy outcomes remains high and inadequately characterised due to the intricate interplay of its etiology and shared set of important risk factors. This study sought to quantify and map the underlying risk of multiple adverse pregnancy outcomes in Kenya at sub-county level using a shared component space-time modelling framework.

Methods

Reported sub-county level adverse pregnancy outcomes count from January 2016 – December 2019 were obtained from the Kenyan District Health Information System. A Bayesian hierarchical spatio-temporal model was used to estimate the joint burden of adverse pregnancy outcomes in space (sub-county) and time (year). To improve the precision of our estimates over time and space, information across the outcomes were combined via the shared and the outcome-specific components using a shared component model with spatio-temporal interactions.

Results

Overall, the total number of adverse outcomes in pregnancy increased by 14.2% (95% UI: 14.0–14.5) from 88,816 cases in 2016 to 101,455 cases in 2019. Between 2016 and 2019, the estimated low birth weight rate and the pre-term birth rate were 4.5 (95% UI: 4.4–4.7) and 2.3 (95% UI: 2.2–2.5) per 100 live births. The stillbirth and neonatal death rates were estimated to be 18.7 (95% UI: 18.0–19.4) and 6.9 (95% UI: 6.4–7.4) per 1000 live births. The magnitude of the spatio-temporal variation attributed to shared risk was high for pre-term births, low birth weight, neonatal deaths, stillbirths and neonatal deaths, respectively. The shared risk patterns were dominant in sub-counties located along the Indian ocean coastline, central and western Kenya.

Conclusions

This study demonstrates the usefulness of a Bayesian joint spatio-temporal shared component model in exploiting specific and shared risk of adverse pregnancy outcomes sub-nationally. By identifying sub-counties with elevated risks and data gaps, our estimates not only assert the need for bolstering maternal health programs in the identified high-risk sub-counties but also provides a baseline against which to assess the progress towards the attainment of Sustainable Development Goals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12210-9.

A Spatial Survival Model for Risk Factors of Under-Five Child Mortality in Kenya

Child mortality is high in Sub-Saharan Africa compared to other regions in the world. In Kenya, the risk of mortality is assumed to vary from county to county due to diversity in socio-economic and even climatic factors. Recently, the country was split into 47 different administrative regions called counties, and health care was delegated to those county governments, further aggravating the spatial differences in health care from county to county. The goal of this study is to evaluate the effects of spatial variation in under-five mortality in Kenya. Data from the Kenya Demographic Health Survey (KDHS-2014) consisting the newly introduced counties was used to analyze this risk. Using a spatial Cox Proportional Hazard model, an Intrinsic Conditional Autoregressive Model (ICAR) was fitted to account for the spatial variation among the counties in the country while the Cox model was used to model the risk factors associated with the time to death of a child. Inference regarding the risk factors and the spatial variation was made in a Bayesian setup based on the Markov Chain Monte Carlo (MCMC) technique to provide posterior estimates. The paper indicate the spatial disparities that exist in the country regarding child mortality in Kenya. The specific counties have mortality rates that are county-specific, although neighboring counties have similar hazards for death of a child. Counties in the central Kenya region were shown to have the highest hazard of death, while those from the western region had the lowest hazard of death. Demographic factors such as the sex of the child and sex of the household head, as well as social economic factors, such as the level of education, accounted for the most variation when spatial differences were factored in. The spatial Cox proportional hazard frailty model performed better compared to the non-spatial non-frailty model. These findings can help the country to plan health care interventions at a subnational level and guide social and health policies by ensuring that counties with a higher risk of Under Five Child Mortality (U5CM) are considered differently from counties experiencing a lower risk of death.

Do agri-food market incentives improve food security and nutrition indicators? a microsimulation evaluation for Kenya

The sustainable development goal #2 aims at ending hunger and malnutrition by 2030. Given the numbers of food insecure and malnourished people on the rise, the heterogeneity of nutritional statuses and needs, and the even worse context of COVID-19 pandemic, this has become an urgent challenge for food-related policies. This paper provides a comprehensive microsimulation approach to evaluate economic policies on food access, sufficiency (energy) and adequacy (protein, fat, carbohydrate) at household level. The improvement in market access conditions in Kenya is simulated as an application case of this method, using original insights from households’ surveys and biochemical and nutritional information by food item. Simulation’s results suggest that improving market access increases food purchasing power overall the country, with a pro-poor impact in rural areas. The daily energy consumption per capita and macronutrients intakes per capita increase at the national level, being the households with at least one stunted child under 5 years old, and poor households living areas outside Mombasa and Nairobi, those which benefit the most. The developed method and its Kenya's application contribute to the discussion on how to evaluate nutrition-sensitive policies, and how to cover most households suffering food insecurity and nutrition deficiencies in any given country.

Improving provision of family planning among pastoralists in Kenya: Perspectives from health care providers, community and religious leaders

There exist significant inequities in access to family planning (FP) in Kenya, particularly for nomadic and semi-nomadic pastoralists. Health care providers (HCP), are key in delivering FP services. Community leaders and religious leaders are also key influencers in women's decisions to use FP. We found limited research exploring the perspectives of both HCPs and these local leaders in this context. We conducted semi-structured interviews with HCPs (n=4) working in facilities in Wajir and Mandera, and community leaders (n=4) and religious leaders (n=4) from the nomadic and semi-nomadic populations the facilities serve. We conducted deductive and inductive thematic analysis. Three overarching themes emerged: perception of FP as a health priority, explanations for low FP use, and recommendations to improve access. Four overlapping sub-themes explained low FP use: desire for large families, tension in FP decision-making, religion and culture, and fears about FP. Providers were from different socio-demographic backgrounds to the communities they served, who faced structural marginalisation from health and other services. Programmes to improve FP access should be delivered alongside interventions targeting the immediate health concerns of pastoralist communities, incorporating structural changes. HCPs that are aware of religious and cultural reasons for non-use, play a key role in improving access.

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.

Trends and determinants of newborn mortality in Kyrgyzstan: a Countdown country case study

BACKGROUND

Kyrgyzstan has made considerable progress in reducing child mortality compared with other countries in the region, despite a comparatively low economic standing. However, maternal mortality is still high. Given the availability of an established birth registration system, we aimed to comprehensively assess the trends and determinants of reproductive, maternal, newborn, and child health in Kyrgyzstan.

METHODS

For this Countdown to 2030 country case study, we used publicly available data repositories and the national birth registry of Kyrgyzstan to examine trends and inequalities of reproductive, maternal, and newborn health and mortality between 1990 and 2018, at a national and subnational level. Coverage of newborn and maternal health interventions was assessed and disaggregated by equity dimensions. We did Oaxaca-Blinder decomposition to determine the contextual factors associated with the observed decline in newborn mortality rates. We also undertook a comprehensive review of national policies and programmes, as well as a prospective Lives Saved Tool analysis, to highlight interventions that have the potential to avert the most maternal, neonatal, and child deaths.

FINDINGS

Over the past two decades, Kyrgyzstan reduced newborn mortality rates by 46% and mortality rates of children younger than 5 years by 69%, whereas maternal mortality rates were reduced by 7% and stillbirth rates by 29%. The leading causes of neonatal deaths were prematurity and asphyxia or hypoxia, and preterm small-for-gestational-age infants were more than 80 times more likely to die in their first month of life compared with those born appropriate-for-gestational age at term. Except for contraceptive use, coverage of essential interventions has increased and is generally high, with limited sociodemographic inequities. With scale-up of a few essential neonatal and maternal interventions, 39% of neonatal deaths, 11% of stillbirths, and 19% of maternal deaths could be prevented by 2030.

INTERPRETATION

Kyrgyzstan has reduced newborn mortality rates considerably, with the potential for further reduction. To achieve and exceed the Sustainable Development Goal 3 targets for newborn survival and reducing stillbirths, Kyrgyzstan needs to scale up packages of interventions for the care of small and sick babies, assure quality of care in all health-care facilities with regionalised perinatal care, and create a linked national registry for mothers and neonates with rapid feedback and accountability.

FUNDING

US Fund for UNICEF under the Countdown to 2015, UNICEF Kyrgyzstan Office.

Trends and Contributing Factors to Contraceptive Use in Kenya: A Large Population-Based Survey 1989 to 2014

Kenya is among the leading nations in family planning in Africa, having the first official nationwide family planning program in sub-Saharan Africa. However, Kenya is still one of the most highly populated countries in Africa with a population of more than 52 million. The objective of this study was to assess the trends and contributing factors of contraceptive use. We conducted a multi-wave cross-sectional study using both the demographic health survey (DHS) and family planning effort index (FPE) datasets, analyzing five-year waves from 1989 to 2014. This study indicates that contraceptive use increased from 24.0% to 42.6%, with a change % of 77.5%. Despite changes in women's characteristics, these characteristics posed little on the time trend of contraceptive use in Kenya. In addition, the policy component of FPE scores had a positive association with contraceptive use with negligible change after adjusting for social and demographic factors 1.055 (1.046-1.065). There was a fluctuating trend of the additional FPE components throughout the years. Women with lower education, those married to husbands with lower education, unmarried, and rural women remain behind in family planning service utilization. Targeted programs are still needed for these special groups. Policy adherence is vital for continued progress.

Determinants of subnational disparities in antenatal care utilisation: a spatial analysis of demographic and health survey data in Kenya

BACKGROUND

The spatial variation in antenatal care (ANC) utilisation is likely associated with disparities observed in maternal and neonatal deaths. Most maternal deaths are preventable through services offered during ANC; however, estimates of ANC coverage at lower decision-making units (sub-county) is mostly lacking. In this study, we aimed to estimate the coverage of at least four ANC (ANC4) visits at the sub-county level using the 2014 Kenya Demographic and Health Survey (KDHS 2014) and identify factors associated with ANC utilisation in Kenya.

METHODS

Data from the KDHS 2014 was used to compute sub-county estimates of ANC4 using small area estimation (SAE) techniques which relied on spatial relatedness to yield precise and reliable estimates at each of the 295 sub-counties. Hierarchical mixed-effect logistic regression was used to identify factors influencing ANC4 utilisation. Sub-county estimates of factors significantly associated with ANC utilisation were produced using SAE techniques and mapped to visualise disparities.

RESULTS

The coverage of ANC4 across sub-counties was heterogeneous, ranging from a low of 17% in Mandera West sub-county to over 77% in Nakuru Town West and Ruiru sub-counties. Thirty-one per cent of the 295 sub-counties had coverage of less than 50%. Maternal education, household wealth, place of delivery, marital status, age at first marriage, and birth order were all associated with ANC utilisation. The areas with low ANC4 utilisation rates corresponded to areas of low socioeconomic status, fewer educated women and a small number of health facility deliveries.

CONCLUSION

Suboptimal coverage of ANC4 and its heterogeneity at sub-county level calls for urgent, focused and localised approaches to improve access to antenatal care services. Policy formulation and resources allocation should rely on data-driven strategies to guide national and county governments achieve equity in access and utilisation of health interventions.

Illicit financial flows and the provision of child and maternal health services in low- and middle-income countries

BACKGROUND

Illicit financial flows (IFFs) drain domestic resources with harmful social effects, especially in countries which are too poor to mobilise the revenues required to finance the provision of essential public goods and services. In this context, this article empirically examined the association between IFFs and the provision of essential health services in low- and middle-income countries.

METHODS

Firstly, a set of indicators was selected to represent the overall coverage of essential health services at the country level. Next, a linear multivariate regression model was specified and estimated for each indicator using cross-sectional data for 72 countries for the period 2008-2013.

RESULTS

After controlling for other relevant factors, the main result of the regression analysis was that an annual 1 percentage point (p.p.) increase in the ratio of IFFs to total trade was associated with a 0.46 p.p. decrease in the level of family planning coverage, a 0.31 p.p. decrease in the percentage of women receiving antenatal care, and a 0.32 p.p. decrease in the level of child vaccination coverage rates.

CONCLUSIONS

These findings suggest that, for the whole sample of countries considered, at least 3.9 million women and 190,000 children may not receive these basic health care interventions in the future as a consequence of a 1 p.p. increase in the ratio of IFFs to total trade. Moreover, given that family planning, reproductive health, and child immunisation are foundational components of health and long-term development in poor countries, the findings show that IFFs could be undermining the achievement of the 2030 Agenda for Sustainable Development.

Association of the US President's Emergency Plan for AIDS Relief's Funding With Prevention of Mother-to-Child Transmission of HIV in Kenya

IMPORTANCE

From 2004 to 2014, the US President's Emergency Plan for AIDS Relief (PEPFAR) invested more than $248 000 000 in the prevention of mother-to-child transmission (PMTCT) of HIV in Kenya. Concurrently, child mortality in Kenya decreased by half.

OBJECTIVE

To identify the extent to which the decrease in child mortality in Kenya is associated with PEPFAR funding for PMTCT of HIV.

DESIGN, SETTING, AND PARTICIPANTS

This population-based survey study conducted in Kenya estimated the association between annual per capita PEPFAR funding for PMTCT (annual PCF) and cumulative per capita PEPFAR funding for PMTCT (cumulative PCF), extracted using 2004-2014 country operational reports as well as individual-level health outcomes, extracted from the 2003, 2008-2009, and 2014 Kenya Demographic and Health Surveys and the 2007 and 2012 Kenya AIDS Indicator Surveys. The study included children of female respondents to the 2003, 2008-2009, and 2014 Kenya Demographic and Health Surveys who were born 1 to 60 months (for neonatal mortality) or 12 to 60 months (for infant mortality) before the survey, as well as female respondents who had recently given birth and reported on HIV testing during antenatal care (ANC) during the 2007-2014 surveys. Results were adjusted for year, province, and survey respondent characteristics. Statistical analysis was performed from July 8, 2016, to December 10, 2018.

MAIN OUTCOMES AND MEASURES

Neonatal mortality was defined as death within the first month of life and infant mortality was defined as death within the first year of life. HIV testing during ANC was defined as receiving counseling on PMTCT, undergoing an HIV test, and receiving test results during ANC.

RESULTS

The analysis included 33 181 neonates (16 870 boys), 26 876 infants (13 679 boys), and 20 775 mothers (mean [SD] age, 28.0 [6.7] years). PEPFAR funding was not associated with neonatal mortality. A $0.33 increase in annual PCF, corresponding to the difference between the 75th and 25th (interquartile range) percentiles of funding, was significantly associated with a 16% (95% CI, 4%-27%) reduction in infant mortality after a 1-year lag. A 14% to 16% reduction persisted after 2- and 3-year lags, and comparable reductions were observed for unlagged and 1-year lagged cumulative PCF. An increase of 1 interquartile range in cumulative PCF was associated with a 7% (95% CI, 3%-11%) increase in HIV testing during ANC, which intensified with subsequent lags. Between 2004 and 2014, sustained funding levels of $0.33 annual PCF could have averted 118 039 to 273 924 infant deaths.

CONCLUSIONS AND RELEVANCE

Evidence from publicly available data suggests that PEPFAR's PMTCT funding was associated with a reduction in infant mortality and an increase in HIV testing during ANC in Kenya. The full outcome of funding may not be realized until several years after allocation.

The impact of the health care workforce on under-five mortality in rural China

BACKGROUND

Previous studies have focused on the relationship between increases in the health care workforce and child health outcomes, but little is known about how this relationship differs in contexts where economic growth differs by initial level and pace. This study evaluates the association between increased health professionals and the under-five mortality rate (U5MR) in rural Chinese counties from 2008 to 2014 and examines whether this relationship differs among counties with different patterns of economic growth over this period.

METHODS

We estimated fixed effects models with rural counties as the unit of analysis to evaluate the association between health professional density and U5MR. Covariates included county-level gross domestic product (GDP) per capita, female illiteracy rate, value of medical equipment per bed, and province-level health expenditures (measured as a proportion of provincial GDP). To explore modification effects, we assessed interactions between health professionals and county types defined by county poverty status and county-level trajectories of growth in GDP per capita. U5MR data have been adjusted for county-level underreporting, and all other data were obtained from administrative and official sources.

RESULTS

The U5MR dropped by 36.19% during the study period. One additional health professional per 1000 population was associated with a 2.6% reduction in U5MR, after controlling for other covariates. County poverty status and GDP trajectories moderated this relationship: the U5MR reductions attributed to a one-unit increase in health professionals were 6.8% among poor counties, but only 1.1% among non-poor ones. These reductions were, respectively, 6.7%, 0.7%, and 4.3% in counties with initially low GDP that slowly increased, medium-level GDP that rose at a moderate pace, and high GDP that rose rapidly.

CONCLUSIONS

This study demonstrates that increased health professionals were associated with reductions in U5MR. The largest association was seen in poor counties and those with low and slowly increasing GDP per capita, which justifies further expansion of the health care workforce in these areas. This study could be instructive for other developing countries to achieve Sustainable Development Goal 3 by helping them identify where additional health professionals would make the greatest contribution.

Sub national variation and inequalities in under-five mortality in Kenya since 1965

Background

Despite significant declines in under five mortality (U5M) over the last 3 decades, Kenya did not achieve Millennium Development Goal 4 (MDG 4) by 2015. To better understand trends and inequalities in child mortality, analysis of U5M variation at subnational decision making units is required. Here the comprehensive compilation and analysis of birth history data was used to understand spatio-temporal variation, inequalities and progress towards achieving the reductions targets of U5M between 1965 and 2013 and projected to 2015 at decentralized health planning units (counties) in Kenya.

Methods

Ten household surveys and three censuses with data on birth histories undertaken between 1989 and 2014 were assembled. The birth histories were allocated to the respective counties and demographic methods applied to estimate U5M per county by survey. To generate a single U5M estimate for year and county, a Bayesian spatio-temporal Gaussian process regression was fitted accounting for variation in sample size, surveys and demographic methods. Inequalities and the progress in meeting the goals set to reduce U5M were evaluated subnationally.

Results

Nationally, U5M reduced by 61·6%, from 141·7 (121·6–164·0) in 1965 to 54·5 (44·6–65·5) in 2013. The declining U5M was uneven ranging between 19 and 80% across the counties with some years when rates increased. By 2000, 25 counties had achieved the World Summit for Children goals. However, as of 2015, no county had achieved MDG 4. There was a striking decline in the levels of inequality between counties over time, however, disparities persist. By 2013 there persists a 3·8 times difference between predicted U5M rates when comparing counties with the highest U5M rates against those with the lowest U5M rates.

Conclusion

Kenya has made huge progress in child survival since independence. However, U5M remains high and heterogeneous with substantial differences between counties. Better use of the current resources through focused allocation is required to achieve further reductions, reduce inequalities and increase the likelihood of achieving Sustainable Development Goal 3·2 on U5M by 2030.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6474-1) contains supplementary material, which is available to authorized users.

Assessment of Inequalities in Coverage of Essential Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions in Kenya

IMPORTANCE

Previous work has underscored subnational inequalities that could impede additional health gains in Kenya.

OBJECTIVE

To provide a comprehensive assessment of the burden, distribution, and change in inequalities in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) interventions in Kenya from 2003 to 2014.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study used data from the 2003, 2008, and 2014 Kenya Demographic and Health Surveys. The study included women of reproductive age (ages 15-49 years) and children younger than years, with national, regional, county, and subcounty level representation. Data analysis was conducted from April 2018 to November 2018.

EXPOSURES

Socioeconomic position that was derived from asset indices and presented as wealth quintiles. Urban and rural residence and regions of Kenya were also considered.

MAIN OUTCOMES AND MEASURES

Absolute and relative measures of inequality in coverage of RMNCAH interventions.

RESULTS

For this analysis, representative samples of 31 380 women of reproductive age and 29 743 children younger than 5 years from across Kenya were included. The RMNCAH interventions examined demonstrated pro-rich and bottom inequality patterns. The most inequitable interventions were skilled birth attendance, family planning needs satisfied, and 4 or more antenatal care visits, whereby the absolute difference in coverage between the wealthiest (quintile 5) and poorest quintiles (quintile 1) was 61.6% (95% CI, 60.1%-63.1%), 33.4% (95% CI, 31.9%-34.9%), and 31.0% (95% CI, 30.5%-31.6%), respectively. The most equitable intervention was early initiation of breastfeeding, with an absolute difference (quintile 5 minus quintile 1) of -7.9% (95% CI, -11.1% to -4.8%), although antenatal care (1 visit) and diphtheria-tetanus-pertussis immunization (3 doses) demonstrated the best combination of high coverage and low inequalities. Our geospatial analysis revealed significant socioeconomic disparities in the northern and eastern regions of Kenya that have translated to suboptimal intervention coverage. A significant gap remains for rural, disadvantaged populations.

CONCLUSIONS AND RELEVANCE

Coverage of RMNCAH interventions has improved over time, but wealth and geospatial inequalities in Kenya are persistent. Policy and programming efforts should place more emphasis on improving the accessibility of health facility-based interventions, which generally demonstrate poor coverage and high inequalities, and focus on integrated approaches to maternal health service delivery at the community level when access is poor. Scaling up of health services for the urban and, in particular, rural poor areas and those residing in Kenya's former north eastern province will contribute toward achievement of universal health coverage.

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

Background

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provided comprehensive estimates of health loss globally. Decision makers in Kenya can use GBD subnational data to target health interventions and address county-level variation in the burden of disease.

Methods

We used GBD 2016 estimates of life expectancy at birth, healthy life expectancy, all-cause and cause-specific mortality, years of life lost, years lived with disability, disability-adjusted life-years, and risk factors to analyse health by age and sex at the national and county levels in Kenya from 1990 to 2016.

Findings

The national all-cause mortality rate decreased from 850·3 (95% uncertainty interval [UI] 829·8–871·1) deaths per 100 000 in 1990 to 579·0 (562·1–596·0) deaths per 100 000 in 2016. Under-5 mortality declined from 95·4 (95% UI 90·1–101·3) deaths per 1000 livebirths in 1990 to 43·4 (36·9–51·2) deaths per 1000 livebirths in 2016, and maternal mortality fell from 315·7 (242·9–399·4) deaths per 100 000 in 1990 to 257·6 (195·1–335·3) deaths per 100 000 in 2016, with steeper declines after 2006 and heterogeneously across counties. Life expectancy at birth increased by 5·4 (95% UI 3·7–7·2) years, with higher gains in females than males in all but ten counties. Unsafe water, sanitation, and handwashing, unsafe sex, and malnutrition were the leading national risk factors in 2016.

Interpretation

Health outcomes have improved in Kenya since 2006. The burden of communicable diseases decreased but continues to predominate the total disease burden in 2016, whereas the non-communicable disease burden increased. Health gains varied strikingly across counties, indicating targeted approaches for health policy are necessary.

Funding

Bill & Melinda Gates Foundation.