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Abstract Background Most children with developmental disabilities (DD) live in low- and middle-income countries, but access to services is limited, impacting their ability to thrive. Pilot study findings of the World Health Organization’s Caregiver Skills Training (WHO CST) intervention, which equips caregivers with strategies to facilitate learning and adaptive behaviours in children with DD, are promising but evidence from an appropriately powered trial delivered by non-specialist facilitators is lacking. This study will investigate the effectiveness and the resource impacts and costs and consequences of the WHO CST intervention in four sites in rural and urban Kenya and Ethiopia. Methods This is a 2-arm multi-site hybrid type-1 effectiveness implementation cluster randomised controlled superiority trial. After baseline assessments (T0) are completed by participants in clusters comprising 7 to 10 caregiver-child dyads, the clusters will be randomised to either the WHO CST intervention arm or a waitlist enhanced care as usual control arm. Further assessments will be completed at endpoint (T1, 18 ± 2 weeks after randomisation) and follow-up (T2, 44 ± 2 weeks after randomisation). The intervention comprises three individualised home visits and nine group sessions with trained non-specialist facilitators. Participants in the control arm will receive the intervention after completing follow-up assessments. We aim to recruit 544 child-caregiver dyads, evenly distributed across the two arms and countries. The co-primary outcomes are the child-focused Child Behavior Checklist (assessing emotional and behavioural problems) and the caregiver-focused Pediatric Quality of Life Inventory (assessing caregiver quality of life), both assessed at endpoint. Secondary outcome measures comprise the two co-primary outcomes at follow-up and ten additional outcome measures at endpoint, assessing stigma-based experiences, depressive symptoms, household food insecurity, child disciplinary strategies and beliefs, CST knowledge and skill competencies, caregiver and child quality of life, social support, and children’s communication modes and functions. After quantitative follow-up assessments are completed, a mixed-methods evaluation approach will be used to investigate implementation processes and acceptability, feasibility, and potential sustainability of the intervention. Discussion The study’s findings will provide evidence of the effectiveness and resource impacts and costs and consequences of a non-specialist-delivered intervention in under-resourced contexts in one low-income and one middle-income country in East Africa. Findings will inform future research, intervention, and policy efforts to support children with DD and their families in under-resourced majority world contexts. Trial registration Pan African Clinical Trial Registry PACTR202310908063134. Registered on October 16, 2023.

Background Effective Public Financial Management (PFM) approaches are imperative in the quest for efficiency in health service delivery. Reviews conducted in this area have assessed the impact of PFM approaches on health system efficiency but have left out the mechanisms through which PFM influences efficiency. This scoping review aims to synthesize evidence on the mechanisms by which PFM influences health system efficiency. Methods We searched databases of PubMed and Google Scholar and websites of the World Health Organization (WHO), World Bank and Overseas Development Institute (ODI) for peer-reviewed and grey literature articles that provided data on the relationship between PFM and health system efficiency. Three reviewers screened the articles for eligibility with the inclusion criteria. Data on PFM and health system efficiency was charted and summarized. We then reported the mechanisms by which PFM influence efficiency. Results PFM processes and structures influence health system efficiency by influencing; the alignment of resources to health system needs, the cost of inputs, the motivation of health workers, and the input mix. Conclusion The entire budget process influences health system efficiency. However, most of the findings are drawn from studies that focused on aspects of the budget process. Studies that look at PFM in totality will help explore other cross-cutting issues within sections of the budget cycle; they will also bring out the relationship between the different phases of the budget cycle.

Introduction There is a growing emphasis on improving primary healthcare (PHC) services and granting frontline service providers more decision-making autonomy. In October 2023, Kenya enacted legislation mandating nationwide facility autonomy. There is limited understanding of the effects of health facility autonomy on PHC facilities performance. It is recognised that stakeholder interests influence reforms, and gender plays a critical role in access to health and its outcomes. This protocol outlines the methods for a study that plans to evaluate the effects, implementation experience, political economy and gendered effects of health facility autonomy reforms in Kenya.Methods and analysis The research will use a before-and-after quasi-experimental study design to measure the effects of the reform on service readiness and service utilisation and a cross-sectional qualitative study to explore the implementation experience, political economy and gendered effects of these reforms. Data to measure the effects of autonomy will be collected from a sample of 80 health facilities and 1600 clients per study arm. Qualitative interviews will involve approximately 83 facility managers and policymakers at the county level, distributed across intervening (36) and planning to intervene (36) counties. Additionally, 11 interviews will be conducted at the national level with representatives from the Ministry of Health, the National Treasury, the Controller of Budget, the Council of Governors, the Auditor General and development partners. Given the uncertainty surrounding the implementation of the reforms, this study proposes two secondary designs in the event our primary design is not feasible—a cross-sectional study and a quasi-experimental interrupted time series design. The study will use a difference-in-difference analysis for the quantitative component to evaluate the effects of the reforms, while using thematic analysis for the qualitative component to evaluate the political economy and the implementation experience of the reforms.Ethics and dissemination This study was approved by the Kenya Medical Research Institute Scientific and Ethics Review Unit (KEMRI/SERU/CGMR-C/294/4708) and the National Commission for Science, Technology and Innovation (NACOSTI/P/23/28111). We plan to disseminate the findings through publications, policy briefs and dissemination workshops.

Abstract Background Kenya aims to achieve universal health coverage (UHC) by 2030 and has selected the National Health Insurance Fund (NHIF) as the ‘vehicle’ to drive the UHC agenda. While there is some progress in moving the country towards UHC, the availability and accessibility to NHIF-contracted facilities may be a barrier to equitable access to care. We estimated the spatial access to NHIF-contracted facilities in Kenya to provide information to advance the UHC agenda in Kenya. Methods We merged NHIF-contracted facility data to the geocoded inventory of health facilities in Kenya to assign facility geospatial locations. We combined this database with covariates data including road network, elevation, land use, and travel barriers. We estimated the proportion of the population living within 60- and 120-minute travel time to an NHIF-contracted facility at a 1-x1-kilometer spatial resolution nationally and at county levels using the WHO AccessMod tool. Results We included a total of 3,858 NHIF-contracted facilities. Nationally, 81.4% and 89.6% of the population lived within 60- and 120-minute travel time to an NHIF-contracted facility respectively. At the county level, the proportion of the population living within 1-hour of travel time to an NHIF-contracted facility ranged from as low as 28.1% in Wajir county to 100% in Nyamira and Kisii counties. Overall, only four counties (Kiambu, Kisii, Nairobi and Nyamira) had met the target of having 100% of their population living within 1-hour (60 min) travel time to an NHIF-contracted facility. On average, it takes 209, 210 and 216 min to travel to an NHIF-contracted facility, outpatient and inpatient facilities respectively. At the county level, travel time to an NHIF-contracted facility ranged from 10 min in Vihiga County to 333 min in Garissa. Conclusion Our study offers evidence of the spatial access estimates to NHIF-contracted facilities in Kenya that can inform contracting decisions by the social health insurer, especially focussing on marginalised counties where more facilities need to be contracted. Besides, this evidence will be crucial as the country gears towards accelerating progress towards achieving UHC using social health insurance as the strategy to drive the UHC agenda in Kenya.

Background Performance-based financing (PBF) was introduced to Kilifi county in Kenya in 2015. This study investigates how and why political and bureaucratic actors at the local level in Kilifi county influenced the extent to which PBF was politically prioritised at the sub-national level.Methods The study employed a single-case study design. The Shiffman and Smith political priority setting framework with adaptations proposed by Walt and Gilson was applied. Data was collected through document review (n = 19) and in-depth interviews (n = 8). Framework analysis was used to analyse data and generate findings.Results In the period 2015-2018, the political prioritisation of PBF at the county level in Kilifi was influenced by contextual features including the devolution of power to sub-national actors and rigid public financial management (PFM) structures. It was further influenced by interpretations of the idea of ‘pay-for-performance,’ its framing as ‘additional funding,’ as well as contestation between actors at the sub national level about key PBF design features. Ultimately PBF ceased at the end of 2018 after donor funding stopped.Conclusion Health reformers must be cognisant of the power and interests of national and sub national actors in all phases of the policy process, including both bureaucratic and political actors in health and non-health sectors. This is particularly important in devolved public governance contexts where reforms require sustained attention and budgetary commitment at the sub national level. There is also need for early involvement of critical actors to develop shared understandings of the ideas on which interventions are premised, as well as problems and solutions.

Background Kenya has experienced several health financing changes that have implications for financing primary healthcare (PHC). These include transitions from funding by two key donors (the World Bank and the Danish International Development Agency (DANIDA)) and the abolishment of conditional grants that were earmarked for financing primary healthcare facilities. This protocol lays out study plans to evaluate the impact and implementation experience of these financing changes on PHC facility functioning and service delivery in Kenya. Methods/design A sequential mixed methods design will be applied to address our research objectives. Firstly, we will perform a document review to understand the evolution of policy changes understudy. Second, we will conduct an interrupted time series analysis across all 47 counties in Kenya to assess these financing changes' impact on health service utilization in all public primary healthcare facilities (level 2 and 3 facilities). Data for this analysis will be obtained from the Kenya Health Information System (KHIS). Third, we will carry out in-depth interviews with health financing stakeholders at the national, county, and health facility levels to examine their perceptions of the experiences with these changes in health financing. Discussion This mixed methods study will contribute to evidence on the sustainability of financing primary healthcare in low and middle-income countries facing financing changes and donor transitions.

Introduction In Kenya, non-communicable diseases (NCDs) are estimated to account for almost one-third of all deaths and this is likely to rise by over 50% in the next 10 years. The Primary Health Integrated Care for Chronic Conditions (PIC4C) project aims to strengthen primary care by integrating comprehensive NCD care into existing HIV primary care platform. This paper evaluates the association of PIC4C implementation on clinical outcomes.Methods Outcomes included proportion of new patients, systolic blood pressure (SBP), fasting plasma glucose (FPG), diastolic blood pressure, hypertension control, random plasma glucose, diabetes control, viral load and HIV viral suppression. We used interrupted time series and binomial regression with random effects for facility-level data and generalised mixed-effects regression for visit-level data to examine the association between PIC4C and outcomes between January 2017 and December 2021. We conducted sensitivity analysis with restrictions on sites and the number of visits.Results Data from 66 641 visits of 13 046 patients with hypertension, 24 005 visits of 7267 patients with diabetes and 84 855 visits of 21 186 people with HIV were analysed. We found evidence of association between PIC4C and increase in proportion of new patients per month with hypertension (adjusted OR (aOR) 1.57, 95% CI 1.39 to 1.78) and diabetes (aOR 1.31, 95% CI 1.19 to 1.45), small increase in SBP (adjusted beta (aB) 1.7, 95% CI 0.8 to 2.7) and FPG (aB 0.6, 95% CI 0.0 to 1.1). There was no strong evidence of association between PIC4C and viral suppression (aOR 1.20, 95% CI 0.98 to 1.47). In sensitivity analysis, there was no strong evidence of association between PIC4C and SBP (aB 1.74, 95% CI −0.70 to 4.17) or FPG (aB 0.52, 95% CI −0.64 to 1.67)Conclusions PIC4C implementation was associated with increase in proportion of new patients attending clinics and a slight increase in SBP and FPG. The immediate post-PIC4C implementation period coincided with the COVID-19 pandemic, which is likely to explain some of our findings.

Abstract Background There is a global interest in institutionalizing health technology assessment (HTA) as an approach for explicit healthcare priority-setting. Institutionalization of HTA refers to the process of conducting and utilizing HTA as a normative practice for guiding resource allocation decisions within the health system. In this study, we aimed to examine the factors that were influencing institutionalization of HTA in Kenya. Methods We conducted a qualitative case study using document reviews and in-depth interviews with 30 participants involved in the HTA institutionalization process in Kenya. We used a thematic approach to analyze the data. Results We found that institutionalization of HTA in Kenya was being supported by factors such as establishment of organizational structures for HTA; availability of legal frameworks and policies on HTA; increasing availability of awareness creation and capacity-building initiatives for HTA; policymakers’ interests in universal health coverage and optimal allocation of resources; technocrats’ interests in evidence-based processes; presence of international collaboration for HTA; and lastly, involvement of bilateral agencies. On the other hand, institutionalization of HTA was being undermined by limited availability of skilled human resources, financial resources, and information resources for HTA; lack of HTA guidelines and decision-making frameworks; limited HTA awareness among subnational stakeholders; and industries’ interests in safeguarding their revenue. Conclusions Kenya’s Ministry of Health can facilitate institutionalization of HTA by adopting a systemic approach that involves: - (a) introducing long-term capacity-building initiatives to strengthen human and technical capacity for HTA; (b) earmarking national health budgets to ensure adequate financial resources for HTA; (c) introducing a cost database and promoting timely data collection to ensure availability of data for HTA; (d) developing context specific HTA guidelines and decision-making frameworks to facilitate HTA processes; (e) conducting deeper advocacy to strengthen HTA awareness among subnational stakeholders; and (f) managing stakeholders’ interests to minimize opposition to institutionalization of HTA.

Abstract Background Non-communicable diseases (NCDs) can impose a substantial financial burden to households in the absence of an effective financial risk protection mechanism. The national health insurance fund (NHIF) has included NCD services in its national scheme. We evaluated the effectiveness of NHIF in providing financial risk protection to households with persons living with hypertension and/or diabetes in Kenya. Methods We carried out a prospective cohort study, following 888 households with at least one individual living with hypertension and/or diabetes for 12 months. The exposure arm comprised households that are enrolled in the NHIF national scheme, while the control arm comprised households that were not enrolled in the NHIF. Study participants were drawn from two counties in Kenya. We used the incidence of catastrophic health expenditure (CHE) as the outcome of interest. We used coarsened exact matching and a conditional logistic regression model to analyse the odds of CHE among households enrolled in the NHIF compared with unenrolled households. Socioeconomic inequality in CHE was examined using concentration curves and indices. Results We found strong evidence that NHIF-enrolled households spent a lower share (12.4%) of their household budget on healthcare compared with unenrolled households (23.2%) (p = 0.004). While households that were enrolled in NHIF were less likely to incur CHE, we did not find strong evidence that they are better protected from CHE compared with households without NHIF (OR = 0.67; p = 0.47). The concentration index (CI) for CHE showed a pro-poor distribution (CI: -0.190, p

BackgroundCommunity pharmacies are the first point of contact for most people seeking treatment for minor illnesses globally. In recent years, the role of community pharmacists has evolved, and they play a significant role in the delivery of public health interventions (PHIs) aimed at health promotion and prevention such as smoking cessation services, weight management services, HIV prevention, and vaccination. This review aims to explore the evidence on the factors that influence community pharmacists to take up the role of delivery of such interventions.MethodsThree electronic databases namely, Embase (1947-December 2023), Medline (1975-December 2023), and Scopus (1823-December 2023) were searched for relevant literature from the inception of the database to December 2023. Reference lists of included articles were also searched for relevant articles. A total of 22 articles were included in the review based on our inclusion and exclusion criteria. The data were analyzed and synthesized using a thematic approach to identify the factors that influence the community pharmacist's decision to take up the role of PHI delivery. Reporting of the findings was done according to the PRISMA checklist.FindingsThe search identified 10,927 articles of which 22 were included in the review. The main factors that drive the delivery of PHIs by community pharmacists were identified as; training and continuous education, remuneration and collaboration with other healthcare professionals. Other factors included structural and workflow adjustments and support from the government and regulatory bodies.ConclusionsEvidence from this review indicates that the decision to expand the scope of practice of community pharmacists is influenced by various factors. Incorporating these factors into the design of policies and public health programs is critical for the successful integration of community pharmacists in the delivery of broader public health to meet the rising demand for health care across health systems.

COVID-19 vaccination rates have been low among adults in Kenya (36.7% as of late March 2023) with vaccine hesitancy posing a threat to the COVID-19 vaccination program. This study sought to examine facilitators and barriers to COVID-19 vaccinations in Kenya. We conducted a qualitative cross-sectional study in two purposively selected counties in Kenya. We collected data through 8 focus group discussions with 80 community members and 8 in-depth interviews with health care managers and providers. The data was analyzed using a framework approach focusing on determinants of vaccine hesitancy and their influence on psychological constructs. Barriers to COVID-19 vaccine uptake were related to individual characteristics (males, younger age, perceived health status, belief in herbal medicine, and the lack of autonomy in decision making among women - especially in rural settings), contextual influences (lifting of bans, myths, medical mistrust, cultural and religious beliefs), and COVID-19 vaccine related factors (fear of unknown consequences, side-effects, lack of understanding on how vaccines work and rationale for boosters). However, community health volunteers, trusted leaders, mandates, financial and geographic access influenced COVID-19 vaccine uptake. These drivers of hesitancy mainly related to psychological constructs including confidence, complacency, and constraints. Vaccine hesitancy in Kenya is driven by multiple interconnected factors. These factors are likely to inform evidence-based targeted strategies that are built on trust to address vaccine hesitancy. These strategies could include gender responsive immunization programs, appropriate messaging and consistent communication that target fear, safety concerns, misconceptions and information gaps in line with community concerns. There is need to ensure that the strategies are tested in the local setting and incorporate a multisectoral approach including community health volunteers, religious leaders and community leaders.

There is global interest in institutionalizing Health Technology Assessment (HTA) to inform resource allocation decisions. However, institutionalization of HTA remains limited particularly in low- and lower-middle-income countries. We conducted this scoping review to synthesize evidence on factors that influence the institutionalization of HTA at the macro (national)-level across countries globally. We searched for relevant literature in six databases namely PubMed, Embase, CINAHL, Scopus, EconLit, and Google Scholar. We conducted the last search on December 31, 2021. We identified 77 articles that described factors that influence institutionalization of HTA across 135 high-, middle-, and low-income countries. We analyzed these articles thematically. We identified five sets of factors that influence the institutionalization of HTA across countries of different income levels. These factors include: (1) organizational resources such as organizational structures, and skilled human, financial, and information resources; (2) legal frameworks, policies, and guidelines for HTA; (3) learning and advocacy for HTA; (4) stakeholder-related factors such as stakeholders’ interests, awareness, and understanding; and (5) collaborative support for HTA through international networks and non-governmental and multi-lateral organizations. Countries seeking to institutionalize HTA should map the availability of the factors identified in this review. Developing these factors wherever necessary can influence a country’s capacity to institutionalize the conduct and use of HTA.

All health systems must set priorities. Evidence-informed priority-setting (EIPS) is a specific form of systematic priority-setting which involves explicit consideration of evidence to determine the healthcare interventions to be provided. The international Decision Support Initiative (iDSI) was established in 2013 as a collaborative platform to catalyze faster progress on EIPS, particularly in low- and middle-income countries. This article summarizes the successes, challenges, and lessons learned from ten years of iDSI partnering with countries to develop EIPS institutions and processes. This is a thematic documentary analysis, structured by iDSI’s theory of change, extracting successes, challenges, and lessons from three external evaluations and 19 internal reports to funders. We identified three phases of iDSI’s work—inception (2013–15), scale-up (2016–2019), and focus on Africa (2019–2023). iDSI has established a global platform for coordinating EIPS, advanced the field, and supported regional networks in Asia and Africa. It has facilitated progress in securing high-level commitment to EIPS, strengthened EIPS institutions, and developed capacity for health technology assessments. This has resulted in improved decisions on service provision, procurement, and clinical care. Major lessons learned include the importance of sustained political will to develop EIPS; a clear EIPS mandate; inclusive governance structures appropriate to health financing context; politically sensitive and country-led support to EIPS, taking advantage of policy windows for EIPS reforms; regional networks for peer support and long-term sustainability; utilization of context appropriate methods such as adaptive HTA; and crucially, donor-funded global health initiatives supporting and integrating with national EIPS systems, not undermining them.

Abstract Background Health systems are complex, consisting of multiple interacting structures and actors whose effective coordination is paramount to enhancing health system goals. Health sector coordination is a potential source of inefficiency in the health sector. We examined how the coordination of the health sector affects health system efficiency in Kenya. Methods We conducted a qualitative cross-sectional study, collecting data at the national level and in two purposely selected counties in Kenya. We collected data using in-depth interviews (n = 37) with national and county-level respondents, and document reviews. We analyzed the data using a thematic approach. Results The study found that while formal coordination structures exist in the Kenyan health system, duplication, fragmentation, and misalignment of health system functions and actor actions compromise the coordination of the health sector. These challenges were observed in both vertical (coordination within the ministry of health, within the county departments of health, and between the national ministry of health and the county department of health) and horizontal coordination mechanisms (coordination between the ministry of health or the county department of health and non-state partners, and coordination among county governments). These coordination challenges are likely to impact the efficiency of the Kenyan health system by increasing the transaction costs of health system functions. Inadequate coordination also impairs the implementation of health programmes and hence compromises health system performance. Conclusion The efficiency of the Kenyan health system could be enhanced by strengthening the coordination of the Kenyan health sector. This can be achieved by aligning and harmonizing the intergovernmental and health sector-specific coordination mechanisms, strengthening the implementation of the Kenya health sector coordination framework at the county level, and enhancing donor coordination through common funding arrangements and integrating vertical disease programs with the rest of the health system. The ministry of health and county departments of health should also review internal organizational structures to enhance functional and role clarity of organizational units and staff, respectively. Finally, counties should consider initiating health sector coordination mechanisms between counties to reduce the fragmentation of health system functions across neighboring counties.

Objectives To illustrate the utility of unsupervised machine learning compared with traditional methods of analysis by identifying archetypes within the population that may be more or less likely to get the COVID-19 vaccine.Design A longitudinal prospective cohort study (n=2009 households) with recurring phone surveys from 2020 to 2022 to assess COVID-19 knowledge, attitudes and practices. Vaccine questions were added in 2021 (n=1117) and 2022 (n=1121) rounds.Setting Five informal settlements in Nairobi, Kenya.Participants Individuals from 2009 households included.Outcome measures and analysis Respondents were asked about COVID-19 vaccine acceptance (February 2021) and vaccine uptake (March 2022). Three distinct clusters were estimated using K-Means clustering and analysed against vaccine acceptance and vaccine uptake outcomes using regression forest analysis.Results Despite higher educational attainment and fewer concerns regarding the pandemic, young adults (cluster 3) were less likely to intend to get the vaccine compared with cluster 1 (41.5% vs 55.3%, respectively; p

Abstract Essential Emergency and Critical Care (EECC) is a novel approach to the care of critically ill patients, focusing on first-tier, effective, low-cost, life-saving care and designed to be feasible even in low-resourced and low-staffed settings. This is distinct from advanced critical care, usually conducted in ICUs with specialised staff, facilities and technologies. This paper estimates the incremental cost of EECC and advanced critical care for the planning of care for critically ill patients in Tanzania and Kenya. The incremental costing took a health systems perspective. A normative approach based on the ingredients defined through the recently published global consensus on EECC was used. The setting was a district hospital in which the patient is provided with the definitive care typically provided at that level for their condition. Quantification of resource use was based on COVID-19 as a tracer condition using clinical expertise. Local prices were used where available, and all costs were converted to USD2020. The costs per patient day of EECC is estimated to be 1 USD, 11 USD and 33 USD in Tanzania and 2 USD, 14 USD and 37 USD in Kenya, for moderate, severe and critical COVID-19 patients respectively. The cost per patient day of advanced critical care is estimated to be 13 USD and 294 USD in Tanzania and USD 17 USD and 345 USD in Kenya for severe and critical COVID-19 patients, respectively. EECC is a novel approach for providing the essential care to all critically ill patients. The low costs and lower tech approach inherent in delivering EECC mean that EECC could be provided to many and suggests that prioritizing EECC over ACC may be a rational approach when resources are limited. Graphical Abstract

Abstract Background Human resources for health consume a substantial share of healthcare resources and determine the efficiency and overall performance of health systems. Under Kenya’s devolved governance, human resources for health are managed by county governments. The aim of this study was to examine how the management of human resources for health influences the efficiency of county health systems in Kenya. Methods We conducted a case study using a mixed methods approach in two purposively selected counties in Kenya. We collected data through in-depth interviews (n = 46) with national and county level HRH stakeholders, and document and secondary data reviews. We analyzed qualitative data using a thematic approach, and quantitative data using descriptive analysis. Results Human resources for health in the selected counties was inadequately financed and there were an insufficient number of health workers, which compromised the input mix of the health system. The scarcity of medical specialists led to inappropriate task shifting where nonspecialized staff took on the roles of specialists with potential undesired impacts on quality of care and health outcomes. The maldistribution of staff in favor of higher-level facilities led to unnecessary referrals to higher level (referral) hospitals and compromised quality of primary healthcare. Delayed salaries, non-harmonized contractual terms and incentives reduced the motivation of health workers. All of these effects are likely to have negative effects on health system efficiency. Conclusions Human resources for health management in counties in Kenya could be reformed with likely positive implications for county health system efficiency by increasing the level of funding, resolving funding flow challenges to address the delay of salaries, addressing skill mix challenges, prioritizing the allocation of health workers to lower-level facilities, harmonizing the contractual terms and incentives of health workers, and strengthening monitoring and supervision.

Abstract Background Vaccines are considered the path out of the COVID-19 pandemic. The government of Kenya is implementing a phased strategy to vaccinate the Kenyan population, initially targeting populations at high risk of severe disease and infection. We estimated the financial and economic unit costs of procuring and delivering the COVID-19 vaccine in Kenya across various vaccination strategies. Methods We used an activity-based costing approach to estimate the incremental costs of COVID-19 vaccine delivery, from a health systems perspective. Document reviews and key informant interviews(n = 12) were done to inform the activities, assumptions and the resources required. Unit prices were derived from document reviews or from market prices. Both financial and economic vaccine procurement costs per person vaccinated with 2-doses, and the vaccine delivery costs per person vaccinated with 2-doses were estimated and reported in 2021USD. Results The financial costs of vaccine procurement per person vaccinated with 2-doses ranged from $2.89-$13.09 in the 30% and 100% coverage levels respectively, however, the economic cost was $17.34 across all strategies. Financial vaccine delivery costs per person vaccinated with 2-doses, ranged from $4.28-$3.29 in the 30% and 100% coverage strategies: While the economic delivery costs were two to three times higher than the financial costs. The total procurement and delivery costs per person vaccinated with 2-doses ranged from $7.34-$16.47 for the financial costs and $29.7-$24.68 for the economic costs for the 30% and 100% coverage respectively. With the exception of procurement costs, the main cost driver of financial and economic delivery costs was supply chain costs (47–59%) and advocacy, communication and social mobilization (29–35%) respectively. Conclusion This analysis presents cost estimates that can be used to inform local policy and may further inform parameters used in cost-effectiveness models. The results could potentially be adapted and adjusted to country-specific assumptions to enhance applicability in similar low-and middle-income settings.

Public Finance Management (PFM) practices influence the attainment of health system goals. PFM processes are implemented within the budget cycle which entails the formulation, execution, and monitoring of government budgets. Budget monitoring and accountability actors, structures, and processes are important in improving the efficiency of health systems. This study examined how the budget monitoring and accountability processes influence the efficiency of county health systems in KenyaWe conducted a qualitative case study of four counties in Kenya selected based on their relative technical efficiency. We collected data using in-depth interviews with health and finance stakeholders (n = 70), and document reviews. We analyzed data using a thematic approach, informed by our study conceptual framework. We found that weak budget monitoring and accountability mechanisms compromised county health system efficiency by a) weakening the effective implementation of the budget formulation and execution steps of the budget cycle, b) enabling the misappropriation of public resources, and c) limiting evidence-informed decision-making by weakening feedback that would be provided by effective monitoring and accountability. Devolution meant that accountability actors were closer to implementation actors which promoted timely problem solving and the relevance of solutions. Internal audit practices were supportive and provided useful feedback to health system managers that facilitated improvements in budget formulation and execution. The efficiency of county health systems can be improved by strengthening the budget monitoring and accountability processes. This can be achieved by increasing the population's budget literacy, supporting participatory budgeting, synchronizing performance and financial accountability, implementing the existent budget monitoring and accountability mechanisms, rewarding efficiency, and sanctioning inefficiency.

Sudden shocks to health systems, such as the COVID-19 pandemic may disrupt health system functions. Health system functions may also influence the health system's ability to deliver in the face of sudden shocks such as the COVID-19 pandemic. We examined the impact of COVID-19 on the health financing function in Kenya, and how specific health financing arrangements influenced the health systems capacity to deliver services during the COVID-19 pandemic.We conducted a cross-sectional study in three purposively selected counties in Kenya using a qualitative approach. We collected data using in-depth interviews (n = 56) and relevant document reviews. We interviewed national level health financing stakeholders, county department of health managers, health facility managers and COVID-19 healthcare workers. We analysed data using a framework approach. Purchasing arrangements: COVID-19 services were partially subsidized by the national government, exposing individuals to out-of-pocket costs given the high costs of these services. The National Health Insurance Fund (NHIF) adapted its enhanced scheme's benefit package targeting formal sector groups to include COVID-19 services but did not make any adaptations to its general scheme targeting the less well-off in society. This had potential equity implications. Public Finance Management (PFM) systems: Nationally, PFM processes were adaptable and partly flexible allowing shorter timelines for budget and procurement processes. At county level, PFM systems were partially flexible with some resource reallocation but maintained centralized purchasing arrangements. The flow of funds to counties and health facilities was delayed and the procurement processes were lengthy. Reproductive and child health services: Domestic and donor funds were reallocated towards the pandemic response resulting in postponement of program activities and affected family planning service delivery. Universal Health Coverage (UHC) plans: Prioritization of UHC related activities was negatively impacted due the shift of focus to the pandemic response. Contrarily the strategic investments in the health sector were found to be a beneficial approach in strengthening the health system. Strengthening health systems to improve their resilience to cope with public health emergencies requires substantial investment of financial and non-financial resources. Health financing arrangements are integral in determining the extent of adaptability, flexibility, and responsiveness of health system to COVID-19 and future pandemics.

In Kenya, non-communicable diseases (NCDs) are an increasingly important cause of morbidity and mortality, requiring both better access to health care services and self-care support. Evidence suggests that treatment burdens can negatively affect adherence to treatment and quality of life. In this study, we explored the treatment and self-management burden among people with NCDs in in two counties in Western Kenya. We conducted a cross-sectional survey of people newly diagnosed with diabetes and/or hypertension, using the Patient Experience with Treatment and Self-Management (PETS) instrument. A total of 301 people with diabetes and/or hypertension completed the survey (63% female, mean age = 57 years). They reported the highest treatment burdens in the domains of medical and health care expenses, monitoring health, exhaustion related to self-management, diet and exercise/physical therapy. Treatment burden scores differed by county, age, gender, education, income and number of chronic conditions. Younger respondents (

Abstract Background Improving health system efficiency is a key strategy to increase health system performance and accelerate progress towards Universal Health Coverage. In 2013, Kenya transitioned into a devolved system of government granting county governments autonomy over budgets and priorities. We assessed the level and determinants of technical efficiency of the 47 county health systems in Kenya. Methods We carried out a two-stage data envelopment analysis (DEA) using Simar and Wilson’s double bootstrap method using data from all the 47 counties in Kenya. In the first stage, we derived the bootstrapped DEA scores using an output orientation. We used three input variables (Public county health expenditure, Private county health expenditure, number of healthcare facilities), and one outcome variable (Disability Adjusted Life Years) using 2018 data. In the second stage, the bias corrected technical inefficiency scores were regressed against 14 exogenous factors using a bootstrapped truncated regression. Results The mean bias-corrected technical efficiency score of the 47 counties was 69.72% (95% CI 66.41–73.01%), indicating that on average, county health systems could increase their outputs by 30.28% at the same level of inputs. County technical efficiency scores ranged from 42.69% (95% CI 38.11–45.26%) to 91.99% (95% CI 83.78–98.95%). Higher HIV prevalence was associated with greater technical inefficiency of county health systems, while higher population density, county absorption of development budgets, and quality of care provided by healthcare facilities were associated with lower county health system inefficiency. Conclusions The findings from this analysis highlight the need for county health departments to consider ways to improve the efficiency of county health systems. Approaches could include prioritizing resources to interventions that will reduce high chronic disease burden, filling structural quality gaps, implementing interventions to improve process quality, identifying the challenges to absorption rates and reforming public finance management systems to enhance their efficiency.

Abstract Background How health facilities are financed affects their performance and health system goals. We examined how health facilities in the public sector are financed in Kenya, within the context of a devolved health system. Methods We carried out a cross-sectional study in five purposely selected counties in Kenya, using a mixed methods approach. We collected data using document reviews and in-depth interviews (no = 20). In each county, we interviewed county department of health managers and health facility managers from two and one purposely selected public hospitals and health center respectively. We analyzed qualitive data using thematic analysis and conducted descriptive analysis of quantitative data. Results Planning and budgeting : Planning and budgeting processes by hospitals and health centers were not standardized across counties. Budgets were not transparent and credible, but rather were regarded as “wish lists” since they did not translate to actual resources. Sources of funds : Public hospitals relied on user fees, while health centers relied on donor funds as their main sources of funding. Funding flows : Hospitals in four of the five study counties had no financial autonomy. Health centers in all study counties had financial autonomy. Flow of funds to hospitals and health centers in all study counties was characterized by unpredictability of amounts and timing. Health facility expenditure: Staff salaries accounted for over 80% of health facility expenditure. This crowded out other expenditure and led to frequent stock outs of essential health commodities. Conclusion The national and county government should consider improving health facility financing in Kenya by 1) standardizing budgeting and planning processes, 2) transitioning public facility financing away from a reliance on user fees and donor funding 3) reforming public finance management laws and carry out political engagement to facilitate direct facility financing and financial autonomy of public hospitals, and 4) assess health facility resource needs to guide appropriate levels resource allocation.

The financing of public health facilities influences their performance. A key feature that defines health facility financing is the degree of financial autonomy. Understanding the factors that influence public health facility financial autonomy is pertinent to developing strategies to addressing challenges that arise from constrained autonomy. In this paper, we apply a complexity lens to draw on a body of research that we have conducted in Kenya over the past decade, from the onset of devolution reforms, to unpack the determinants of public health facility financial autonomy in a context of decentralisation and provide suggestions for pertinent considerations when designing interventions to address financial autonomy challenges. We find that the factors that affect public health facility autonomy are not only structural, but also procedural, and political and interact in complex ways. These factors include; the public finance management (PFM) laws, sense-making by actors in the health system, political interests in control over resources, subnational level PFM capacity, PFM implementation bottlenecks and broader operational autonomy. Drawing from this analysis, we recommend that efforts at resolving public health facility financial autonomy include: PFM capacity development for subnational levels of government in decentralised settings, the use of a political lens that recognises interests and seeks to align incentives in engagement and solution finding for health facility financial autonomy, the audit of PFM processes to establish and resolve implementation bottlenecks that impinge on public health facility autonomy, and the resolution of operational autonomy to as a facilitator of financial autonomy.

Policymakers in Africa need robust estimates of the current and future spread of SARS-CoV-2. We used national surveillance PCR test, serological survey and mobility data to develop and fit a county-specific transmission model for Kenya up to the end of September 2020, which encompasses the first wave of SARS-CoV-2 transmission in the country. We estimate that the first wave of the SARS-CoV-2 pandemic peaked before the end of July 2020 in the major urban counties, with 30-50% of residents infected. Our analysis suggests, first, that the reported low COVID-19 disease burden in Kenya cannot be explained solely by limited spread of the virus, and second, that a 30-50% attack rate was not sufficient to avoid a further wave of transmission.

SARS-CoV-2 was first detected in Kenya in March 2020 and there was evidence of local transmission in the following months. Here, the authors characterise the early stages of the epidemic in coastal Kenya using phylogenetics and find evidence of multiple strain importations from international points of entry.

Abstract Background The COVID-19 pandemic and country measures to control it can lead to negative indirect health effects. Understanding these indirect health effects is important in informing strategies to mitigate against them. This paper presents an analysis of the indirect health effects of the pandemic in Kenya. Methods We employed a mixed-methods approach, combining the analysis of secondary quantitative data obtained from the Kenya Health Information System database (from January 2019 to November 2020) and a qualitative inquiry involving key informant interviews (n = 12) and document reviews. Quantitative data were analysed using an interrupted time series analysis (using March 2020 as the intervention period). Thematic analysis approach was employed to analyse qualitative data. Results Quantitative findings show mixed findings, with statistically significant reduction in inpatient utilization, and increase in the number of sexual violence cases per OPD visit that could be attributed to COVID-19 and its mitigation measures. Key informants reported that while financing of essential health services and domestic supply chains were not affected, international supply chains, health workforce, health infrastructure, service provision, and patient access were disrupted. However, the negative effects were thought to be transient, with mitigation measures leading to a bounce back. Conclusion Finding from this study provide some insights into the effects of the pandemic and its mitigation measures in Kenya. The analysis emphasizes the value of strategies to minimize these undesired effects, and the critical role that routine health system data can play in monitoring continuity of service delivery.

The reported burden of SARS-CoV-2 has been relatively low in tropical Africa compared to Europe and the Americas, but estimating true infection rates is challenging. Here, the authors screen blood donors in Kenya for SARS-CoV-2 antibodies and describe spatiotemporal seroprevalence dynamics.

Background A few studies have assessed the epidemiological impact and the cost-effectiveness of COVID-19 vaccines in settings where most of the population had been exposed to SARS-CoV-2 infection.Methods We conducted a cost-effectiveness analysis of COVID-19 vaccine in Kenya from a societal perspective over a 1.5-year time frame. An age-structured transmission model assumed at least 80% of the population to have prior natural immunity when an immune escape variant was introduced. We examine the effect of slow (18 months) or rapid (6 months) vaccine roll-out with vaccine coverage of 30%, 50% or 70% of the adult (>18 years) population prioritising roll-out in those over 50-years (80% uptake in all scenarios). Cost data were obtained from primary analyses. We assumed vaccine procurement at US$7 per dose and vaccine delivery costs of US$3.90–US$6.11 per dose. The cost-effectiveness threshold was US$919.11.Findings Slow roll-out at 30% coverage largely targets those over 50 years and resulted in 54% fewer deaths (8132 (7914–8373)) than no vaccination and was cost saving (incremental cost-effectiveness ratio, ICER=US$−1343 (US$−1345 to US$−1341) per disability-adjusted life-year, DALY averted). Increasing coverage to 50% and 70%, further reduced deaths by 12% (810 (757–872) and 5% (282 (251–317) but was not cost-effective, using Kenya’s cost-effectiveness threshold (US$919.11). Rapid roll-out with 30% coverage averted 63% more deaths and was more cost-saving (ICER=US$−1607 (US$−1609 to US$−1604) per DALY averted) compared with slow roll-out at the same coverage level, but 50% and 70% coverage scenarios were not cost-effective.Interpretation With prior exposure partially protecting much of the Kenyan population, vaccination of young adults may no longer be cost-effective.

Attention has turned to improving the quality and safety of healthcare within health facilities to reduce avoidable mortality and morbidity. Interventions should be tested in health system environments that can support their adoption if successful. To be successful, interventions often require changes in multiple behaviours making their consequences unpredictable. Here, we focus on this challenge of change at the mesolevel or microlevel. Drawing on multiple insights from theory and our own empirical work, we highlight the importance of engaging managers, senior and frontline staff and potentially patients to explore foundational questions examining three core resource areas. These span the physical or material resources available, workforce capacity and capability and team and organisational relationships. Deficits in all these resource areas may need to be addressed to achieve success. We also argue that as inertia is built into the complex social and human systems characterising healthcare facilities that thought on how to mobilise five motive forces is needed to help achieve change. These span goal alignment and ownership, leadership for change, empowering key actors, promoting responsive planning and procurement and learning for transformation. Our aim is to bridge the theory—practice gap and offer an entry point for practical discussions to elicit the critical tacit and contextual knowledge needed to design interventions. We hope that this may improve the chances that interventions are successful and so contribute to better facility-based care and outcomes while contributing to the development of learning health systems.

Covid-19 requires policy makers to consider evidence on both population health and economic welfare. Over the last two decades, the field of health economics has developed a range of analytical approaches and contributed to the institutionalisation of processes to employ economic evidence in health policy. We present a discussion outlining how these approaches and processes need to be applied more widely to inform Covid-19 policy; highlighting where they may need to be adapted conceptually and methodologically, and providing examples of work to date. We focus on the evidential and policy needs of low- and middle-income countries; where there is an urgent need for evidence to navigate the policy trade-offs between health and economic well-being posed by the Covid-19 pandemic.

Objective: To estimate the economic impact of border closure and social distancing by estimating the decline of gross domestic product (GDP) in Kenya, Singapore and Thailand.Methods: We analysed secondary data retrospectively. To calculate impact of NPIs on GDP, the relationship between GDP and stock market index was examined using ordinary least squares (OLS). Then, autoregressive and moving averages (ARMA) model was used to examine the impact of NPI on stock market index. The change in GDP due to NPIs was derived by multiplying coefficients of OLS and ARMA models.Results: An increase in stock market index correlated with an increase in GDP, while both social distancing and border closure negatively correlated with stock market index. Implementation of NPIs correlated with the decline in GDP. Thai border closure had a greater decline in GDP than social distancing; Kenya exhibited the same trends; Singapore had the opposite trend.Conclusion: We quantified the magnitude of economic impact of NPIs in terms of GDP decline by linking stock market index and GDP. This approach may be applicable in other settings.

Background: Detailed understanding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) regional transmission networks within sub-Saharan Africa is key for guiding local public health interventions against the pandemic. Methods: Here, we analysed 1139 SARS-CoV-2 genomes from positive samples collected between March 2020 and February 2021 across six counties of Coastal Kenya (Mombasa, Kilifi, Taita Taveta, Kwale, Tana River, and Lamu) to infer virus introductions and local transmission patterns during the first two waves of infections. Virus importations were inferred using ancestral state reconstruction, and virus dispersal between counties was estimated using discrete phylogeographic analysis. Results: During Wave 1, 23 distinct Pango lineages were detected across the six counties, while during Wave 2, 29 lineages were detected; 9 of which occurred in both waves and 4 seemed to be Kenya specific (B.1.530, B.1.549, B.1.596.1, and N.8). Most of the sequenced infections belonged to lineage B.1 (n = 723, 63%), which predominated in both Wave 1 (73%, followed by lineages N.8 [6%] and B.1.1 [6%]) and Wave 2 (56%, followed by lineages B.1.549 [21%] and B.1.530 [5%]). Over the study period, we estimated 280 SARS-CoV-2 virus importations into Coastal Kenya. Mombasa City, a vital tourist and commercial centre for the region, was a major route for virus imports, most of which occurred during Wave 1, when many Coronavirus Disease 2019 (COVID-19) government restrictions were still in force. In Wave 2, inter-county transmission predominated, resulting in the emergence of local transmission chains and diversity. Conclusions: Our analysis supports moving COVID-19 control strategies in the region from a focus on international travel to strategies that will reduce local transmission. Funding: This work was funded by The Wellcome (grant numbers: 220985, 203077/Z/16/Z, 220977/Z/20/Z, and 222574/Z/21/Z) and the National Institute for Health and Care Research (NIHR), project references: 17/63/and 16/136/33 using UK Aid from the UK government to support global health research, The UK Foreign, Commonwealth and Development Office. The views expressed in this publication are those of the author(s) and not necessarily those of the funding agencies.

Abstract Background The World Health Organisation framed responsiveness, fair financing and equity as intrinsic goals of health systems. However, of the three, responsiveness received significantly less attention. Responsiveness is essential to strengthen systems’ functioning; provide equitable and accountable services; and to protect the rights of citizens. There is an urgency to make systems more responsive, but our understanding of responsiveness is limited. We therefore sought to map existing evidence on health system responsiveness. Methods A mixed method systemized evidence mapping review was conducted. We searched PubMed, EbscoHost, and Google Scholar. Published and grey literature; conceptual and empirical publications; published between 2000 and 2020 and English language texts were included. We screened titles and abstracts of 1119 publications and 870 full texts. Results Six hundred twenty-one publications were included in the review. Evidence mapping shows substantially more publications between 2011 and 2020 (n = 462/621) than earlier periods. Most of the publications were from Europe (n = 139), with more publications relating to High Income Countries (n = 241) than Low-to-Middle Income Countries (n = 217). Most were empirical studies (n = 424/621) utilized quantitative methodologies (n = 232), while qualitative (n = 127) and mixed methods (n = 63) were more rare. Thematic analysis revealed eight primary conceptualizations of ‘health system responsiveness’, which can be fitted into three dominant categorizations: 1) unidirectional user-service interface; 2) responsiveness as feedback loops between users and the health system; and 3) responsiveness as accountability between public and the system. Conclusions This evidence map shows a substantial body of available literature on health system responsiveness, but also reveals evidential gaps requiring further development, including: a clear definition and body of theory of responsiveness; the implementation and effectiveness of feedback loops; the systems responses to this feedback; context-specific mechanism-implementation experiences, particularly, of LMIC and fragile-and conflict affected states; and responsiveness as it relates to health equity, minority and vulnerable populations. Theoretical development is required, we suggest separating ideas of services and systems responsiveness, applying a stronger systems lens in future work. Further agenda-setting and resourcing of bridging work on health system responsiveness is suggested.

ABSTRACTMany countries in sub-Saharan Africa have implemented performance-based financing (PBF) to improve health system performance. Much of the debate and analysis relating to PBF has focused on whether PBF “works”—that is, whether it leads to improvements in indicators tied to incentive-based payments. Because PBF schemes embody key elements of strategic health purchasing, this study examines the question of whether and how PBF programs in sub-Saharan Africa influence strategic purchasing more broadly within country health financing arrangements. We searched PubMed, Scopus, EconLit, Cochrane Database of Systematic Reviews, Google Scholar, Google, and the World Health Organization and World Bank’s repositories for studies that focused on the implementation experience or effects of PBF in sub-Saharan African and published in English from 2000 to 2020. We identified 44 papers and used framework analysis to analyze the data and generate key findings. The evidence we reviewed shows that PBF has the potential to raise awareness about strategic purchasing, improve governance and institutional arrangements, and strengthen strategic purchasing functions. However, these effects are minimal in practice because PBF has been introduced as narrow, often pilot, projects that run parallel to and have little integration with the mainstream health financing system. We concluded that PBF has not systematically transformed health purchasing in countries in sub-Saharan Africa but that the experience with PBF can provide valuable lessons for how system-wide strategic purchasing can be implemented most effectively in that region—either in countries that currently have PBF schemes and aim to integrate them into broader purchasing systems, or in countries that are not currently implementing PBF. We also concluded that for countries to pursue more holistic approaches to strategic health purchasing and achieve better health outcomes, they need to implement health financing reforms within or aligned with existing financing systems.

ABSTRACTThe Strategic Purchasing Africa Resource Center (SPARC) developed a framework for tracking strategic purchasing that uses a functional and practical approach to describe, assess, and strengthen purchasing to facilitate policy dialogue within countries. This framework was applied in nine African countries to assess their progress on strategic purchasing. This paper summarizes overarching lessons from the experiences of the nine countries. In each country, researchers populated a Microsoft Excel–based matrix using data collected through document reviews and key informant interviews conducted between September 2019 and March 2021. The matrix documented governance arrangements; core purchasing functions (benefits specification, contracting arrangements, provider payment, and performance monitoring); external factors affecting purchasing; and results attributable to the implementation of these purchasing functions. SPARC and its partners synthesized information from the country assessments to draw lessons applicable to strategic purchasing in Africa. All nine countries have fragmented health financing systems, each with distinct purchasing arrangements. Countries have made some progress in specifying a benefit package that addresses the health needs of the most vulnerable groups and entering into selective contracts with mostly private providers that specify expectations and priorities. Progress on provider payment and performance monitoring has been limited. Overall, progress on strategic purchasing has been limited in most of the countries and has not led to large-scale health system improvements because of the persistence of out-of-pocket payments as the main source of health financing and the high degree of fragmentation, which limits purchasing power to allocate resources and incentivize providers to improve productivity and quality of care.

ABSTRACTKenya has implemented several health purchasing reforms to facilitate progress toward universal health coverage. We conducted a narrative review of peer-reviewed and grey literature to examine how these reforms have affected health system outcomes in terms of equity, access, quality of care, and financial protection. We categorized the purchasing reforms we identified into the areas of benefits specification, provider payment, and performance monitoring. We found that the introduction and expansion of benefit packages for maternity, outpatient, and specialized services improved responsiveness to population needs and enhanced protection from financial hardship. However, access to service entitlements was limited by inadequate awareness of the covered services among providers and lack of service availability at contracted facilities. Provider payment reforms increased health facilities’ access to funds, which enhanced service delivery, quality of care, and staff motivation. But delays and the perceived inadequacy of payment rates incentivized negative provider behavior, which limited access to care and exposed patients to out-of-pocket payments. We found that performance monitoring reforms improved the quality assurance capacity of the public insurer and enhanced patient safety, service utilization, and quality of care provided by facilities. Although health purchasing reforms have improved access, quality of care, and financial risk protection to some extent in Kenya, they should be aligned and implemented jointly rather than as individual interventions. Measures that policymakers might consider include strengthening communication of health benefits, timely and adequate payment of providers, and enhancing health facility autonomy over the revenues they generate.

Introduction Amid the rising number of people with non-communicable diseases (NCDs), Kenya has invested in strengthening primary care and in efforts to expand existing service delivery platforms to integrate NCD care. One such approach is the AMPATH (Academic Model Providing Access to Healthcare) model in western Kenya, which provides the platform for the Primary Health Integrated Care Project for Chronic Conditions (PIC4C), launched in 2018 to further strengthen primary care services for the prevention and control of hypertension, diabetes, breast and cervical cancer. This study seeks to understand how well PIC4C delivers on its intended aims and to inform and support scale up of the PIC4C model for integrated care for people with NCDs in Kenya.Methods and analysis The study is guided by a conceptual framework on implementing, sustaining and spreading innovation in health service delivery. We use a multimethod design combining qualitative and quantitative approaches, involving: (1) in-depth interviews with health workers and decision-makers to explore experiences of delivering PIC4C; (2) a cross-sectional survey of patients with diabetes or hypertension and in-depth interviews to understand how well PIC4C meets patients’ needs; (3) a cohort study with an interrupted time series analysis to evaluate the degree to which PIC4C leads to health benefits such as improved management of hypertension or diabetes; and (4) a cohort study of households to examine the extent to which the national hospital insurance chronic care package provides financial risk protection to people with hypertension or diabetes within PIC4C.Ethics and dissemination The study has received approvals from Moi University Institutional Research and Ethics Committee (FAN:0003586) and the London School of Hygiene & Tropical Medicine (17940). Workshops with key stakeholders at local, county, national and international levels will ensure early and wide dissemination of our findings to inform scale up of this model of care. We will also publish findings in peer-reviewed journals.

BackgroundViolence against women and girls (VAWG) is a human rights violation with social, economic, and health consequences for survivors, perpetrators, and society. Robust evidence on economic, social, and health impact, plus the cost of delivery of VAWG prevention, is critical to making the case for investment, particularly in low- and middle-income countries (LMICs) where health sector resources are highly constrained. We report on the costs and health impact of VAWG prevention in 6 countries.Methods and findingsWe conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from 5 randomised controlled trials (RCTs) in sub-Saharan Africa and 1 in South Asia. We evaluated 2 school-based interventions aimed at adolescents (11 to 14 years old) and 2 workshop-based (small group or one to one) interventions, 1 community-based intervention, and 1 combined small group and community-based programme all aimed at adult men and women (18+ years old). All interventions were delivered between 2015 and 2018 and were compared to a do-nothing scenario, except for one of the school-based interventions (government-mandated programme) and for the combined intervention (access to financial services in small groups). We computed the health burden from VAWG with disability-adjusted life year (DALY). We estimated per capita DALYs averted using statistical models that reflect each trial's design and any baseline imbalances. We report cost-effectiveness as cost per DALY averted and characterise uncertainty in the estimates with probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a subgroup analysis of the small group component of the combined intervention and no other subgroup analysis. We also report an impact inventory to illustrate interventions' socioeconomic impact beyond health. We use a 3% discount rate for investment costs and a 1-year time horizon, assuming no effects post the intervention period. From a health sector perspective, the cost per DALY averted varies between US$222 (2018), for an established gender attitudes and harmful social norms change community-based intervention in Ghana, to US$17,548 (2018) for a livelihoods intervention in South Africa. Taking a societal perspective and including wider economic impact improves the cost-effectiveness of some interventions but reduces others. For example, interventions with positive economic impacts, often those with explicit economic goals, offset implementation costs and achieve more favourable cost-effectiveness ratios. Results are robust to sensitivity analyses. Our DALYs include a subset of the health consequences of VAWG exposure; we assume no mortality impact from any of the health consequences included in the DALYs calculations. In both cases, we may be underestimating overall health impact. We also do not report on participants' health costs.ConclusionsWe demonstrate that investment in established community-based VAWG prevention interventions can improve population health in LMICs, even within highly constrained health budgets. However, several VAWG prevention interventions require further modification to achieve affordability and cost-effectiveness at scale. Broadening the range of social, health, and economic outcomes captured in future cost-effectiveness assessments remains critical to justifying the investment urgently required to prevent VAWG globally.

Abstract Background Many low- and middle-income countries have implemented control measures against coronavirus disease 2019 (COVID-19). However, it is not clear to what extent these measures explain the low numbers of recorded COVID-19 cases and deaths in Africa. One of the main aims of control measures is to reduce respiratory pathogen transmission through direct contact with others. In this study, we collect contact data from residents of informal settlements around Nairobi, Kenya, to assess if control measures have changed contact patterns, and estimate the impact of changes on the basic reproduction number (R 0). Methods We conducted a social contact survey with 213 residents of five informal settlements around Nairobi in early May 2020, 4 weeks after the Kenyan government introduced enhanced physical distancing measures and a curfew between 7 pm and 5 am. Respondents were asked to report all direct physical and non-physical contacts made the previous day, alongside a questionnaire asking about the social and economic impact of COVID-19 and control measures. We examined contact patterns by demographic factors, including socioeconomic status. We described the impact of COVID-19 and control measures on income and food security. We compared contact patterns during control measures to patterns from non-pandemic periods to estimate the change in R 0 . Results We estimate that control measures reduced physical contacts by 62% and non-physical contacts by either 63% or 67%, depending on the pre-COVID-19 comparison matrix used. Masks were worn by at least one person in 92% of contacts. Respondents in the poorest socioeconomic quintile reported 1.5 times more contacts than those in the richest. Eighty-six percent of respondents reported a total or partial loss of income due to COVID-19, and 74% reported eating less or skipping meals due to having too little money for food. Conclusion COVID-19 control measures have had a large impact on direct contacts and therefore transmission, but have also caused considerable economic and food insecurity. Reductions in R 0 are consistent with the comparatively low epidemic growth in Kenya and other sub-Saharan African countries that implemented similar, early control measures. However, negative and inequitable impacts on economic and food security may mean control measures are not sustainable in the longer term.

Abstract Background Health sector priority setting in Low and Middle-Income Countries (LMICs) entails balancing between a high demand and low supply of scarce resources. Human Resources for Health (HRH) consume the largest allocation of health sector resources in LMICs. Health sector decentralization continues to be promoted for its perceived ability to improve efficiency, relevance and participation in health sector priority setting. Following the 2013 devolution in Kenya, both health service delivery and human resource management were decentralized to county level. Little is known about priority setting practices and outcomes of HRH within decentralized health systems in LMICs. Our study sought to examine if and how the Kenyan devolution has improved health sector priority setting practices and outcomes for HRH. Methods We used a mixed methods case study design to examine health sector priority setting practices and outcomes at county level in Kenya. We used three sources of data. First, we reviewed all relevant national and county level policy and guidelines documents relating to HRH management. We then accessed and reviewed county records of HRH recruitment and distribution between 2013 and 2018. We finally conducted eight key informant interviews with various stakeholder involved in HRH priority setting within our study county. Results We found that HRH numbers in the county increased by almost two-fold since devolution. The county had two forms of HRH recruitment: one led by the County Public Services Board as outlined by policy and guidelines and a parallel, politically-driven recruitment done directly by the County Department of Health. Though there were clear guidelines on HRH recruitment, there were no similar guidelines on allocation and distribution of HRH. Since devolution, the county has preferentially staffed higher level hospitals over primary care facilities. Additionally, there has been local county level innovations to address some HRH management challenges, including recruiting doctors and other highly specialized staff on fixed term contract as opposed to permanent basis; and implementation of local incentives to attract and retain HRH to remote areas within the county. Conclusion Devolution has significantly increased county level decision-space for HRH priority setting in Kenya. However, HRH management and accountability challenges still exist at the county level. There is need for interventions to strengthen county level HRH management capacity and accountability mechanisms beyond additional resources allocation. This will boost the realization of the country’s efforts for promoting service delivery equity as a key goal – both for the devolution and the country’s quest towards Universal Health Coverage (UHC).

Abstract Background There is substantial burden of seasonal influenza in Kenya, which led the government to consider introducing a national influenza vaccination programme. Given the cost implications of a nationwide programme, local economic evaluation data are needed to inform policy on the design and benefits of influenza vaccination. We set out to estimate the cost-effectiveness of seasonal influenza vaccination in Kenya. Methods We fitted an age-stratified dynamic transmission model to active surveillance data from patients with influenza from 2010 to 2018. Using a societal perspective, we developed a decision tree cost-effectiveness model and estimated the incremental cost-effectiveness ratio (ICER) per disability-adjusted life year (DALY) averted for three vaccine target groups: children 6–23 months (strategy I), 2–5 years (strategy II) and 6–14 years (strategy III) with either the Southern Hemisphere influenza vaccine (Strategy A) or Northern Hemisphere vaccine (Strategy B) or both (Strategy C: twice yearly vaccination campaigns, or Strategy D: year-round vaccination campaigns). We assessed cost-effectiveness by calculating incremental net monetary benefits (INMB) using a willingness-to-pay (WTP) threshold of 1–51% of the annual gross domestic product per capita ($17–$872). Results The mean number of infections across all ages was 2–15 million per year. When vaccination was well timed to influenza activity, the annual mean ICER per DALY averted for vaccinating children 6–23 months ranged between $749 and $1385 for strategy IA, $442 and $1877 for strategy IB, $678 and $4106 for strategy IC and $1147 and $7933 for strategy ID. For children 2–5 years, it ranged between $945 and $1573 for strategy IIA, $563 and $1869 for strategy IIB, $662 and $4085 for strategy IIC, and $1169 and $7897 for strategy IID. For children 6–14 years, it ranged between $923 and $3116 for strategy IIIA, $1005 and $2223 for strategy IIIB, $883 and $4727 for strategy IIIC and $1467 and $6813 for strategy IIID. Overall, no vaccination strategy was cost-effective at the minimum ($17) and median ($445) WTP thresholds. Vaccinating children 6–23 months once a year had the highest mean INMB value at $872 (WTP threshold upper limit); however, this strategy had very low probability of the highest net benefit. Conclusion Vaccinating children 6–23 months once a year was the most favourable vaccination option; however, the strategy is unlikely to be cost-effective given the current WTP thresholds.

Abstract Background In 2004, The Kenyan government removed user fees in public dispensaries and health centers and replaced them with registration charges of 10 and 20 Kenyan shillings (2004 $US 0.13 and $0.25), respectively. This was termed the 10/20 policy. We examined the effect of this policy on the coverage, timing, source, and content of antenatal care (ANC), and the equity in these outcomes. Methods Data from the 2003, 2008/9 and 2014 Kenya Demographic and Health Surveys were pooled to investigate women’s ANC care-seeking. We conducted an interrupted time series analysis to assess the impact of the 10/20 policy on the levels of and trends in coverage for 4+ ANC contacts among all women; early ANC initiation and use of public facility-based care among 1+ ANC users; and use of public primary care facilities and receipt of good content, or quality, of ANC among users of public facilities. All analyses were conducted at the population level and separately for women with higher and lower household wealth. Results The policy had positive effects on use of 4+ ANC among both better-off and worse-off women. Among users of 1+ ANC, the 10/20 policy had positive effects on early ANC initiation at the population-level and among better-off women, but not among the worse-off. The policy was associated with reduced use of public facility-based ANC among better-off women. Among worse-off users of public facility-based ANC, the 10/20 policy was associated with reduced use of primary care facilities and increased content of ANC. Conclusions This study highlights mixed findings on the impact of the 10/20 policy on ANC service-seeking and content of care. Given the reduced use of public facilities among the better-off and of primary care facilities among the worse-off, this research also brings into question the mechanisms through which the policy achieved any benefits and whether reducing user fees is sufficient for equitably increasing healthcare access.

Abstract Background Kenya has prioritized the attainment of universal health coverage (UHC) through the expansion of health insurance coverage by the National Hospital Insurance Fund (NHIF). In 2015, the NHIF introduced reforms in premium contribution rates, benefit packages, and provider payment methods. We examined the influence of these reforms on NHIF’s purchasing practices and their implications for strategic purchasing and health system goals of equity, efficiency and quality. Methods We conducted an embedded case study with the NHIF as the case and the reforms as embedded units of analysis. We collected data at the national level and in two purposively selected counties through 41 in-depth interviews with health financing stakeholders, facility managers and frontline providers; 4 focus group discussions with 51 NHIF members; and, document reviews. We analysed the data using a Framework approach. Results The new NHIF reforms were characterized by weak purchasing actions. Firstly, the new premium contribution rates were inadequately communicated and unaffordable for certain citizen groups. Secondly, while the new benefit packages were reported to be based on service needs, preferences and values of the population, they were inadequately communicated and unequally distributed across different citizen groups. In addition, the presence of service delivery infrastructure gaps in public healthcare facilities and the pro-urban and pro-private distribution of contracted health facilities compromised delivery of, and access to, these new services. Lastly, the new provider payment methods and rates were considered inadequate, with delayed payments and weak links to financial accountability mechanisms which compromised their ability to incentivize equity, efficiency and quality of healthcare delivery. Conclusion While NHIF sought to expand population and service coverage and reduce out-of-pocket payments with the new reforms, weaknesses in the reforms’ design and implementation limited NHIF’s purchasing actions with negative implications for the health system goals of equity, efficiency and quality. For the reforms to accelerate the country’s progress towards UHC, policy makers at the NHIF and, national and county government should make deliberate efforts to align the design and implementation of such reforms with strategic purchasing actions that are aimed at improving health system goals.

Abstract Background While health worker strikes are experienced globally, the effects can be worst in countries with infrastructural and resource challenges, weak institutional arrangements, underdeveloped organizational ethics codes, and unaffordable alternative options for the poor. In Kenya, there have been a series of public health worker strikes in the post devolution period. We explored the perceptions and experiences of frontline health managers and community members of the 2017 prolonged health workers’ strikes. Methods We employed an embedded research approach in one county in the Kenyan Coast. We collected in-depth qualitative data through informal observations, reflective meetings, individual and group interviews and document reviews (n = 5), and analysed the data using a thematic approach. Individual interviews were held with frontline health managers (n = 26), and group interviews with community representatives (4 health facility committee member groups, and 4 broader community representative groups). Interviews were held during and immediately after the nurses’ strike. Findings In the face of major health facility and service closures and disruptions, frontline health managers enacted a range of strategies to keep key services open, but many strategies were piecemeal, inconsistent and difficult to sustain. Interviewees reported huge negative health and financial strike impacts on local communities, and especially the poor. There is limited evidence of improved health system preparedness to cope with any future strikes. Conclusion Strikes cannot be seen in isolation of the prevailing policy and health systems context. The 2017 prolonged strikes highlight the underlying and longer-term frustration amongst public sector health workers in Kenya. The health system exhibited properties of complex adaptive systems that are interdependent and interactive. Reactive responses within the public system and the use of private healthcare led to limited continued activity through the strike, but were not sufficient to confer resilience to the shock of the prolonged strikes. To minimise the negative effects of strikes when they occur, careful monitoring and advanced planning is needed. Planning should aim to ensure that emergency and other essential services are maintained, threats between staff are minimized, health worker demands are reasonable, and that governments respect and honor agreements.

Policymakers in Africa need robust estimates of the current and future spread of SARS-CoV-2. We used national surveillance PCR test, serological survey and mobility data to develop and fit a county-specific transmission model for Kenya up to the end of September 2020, which encompasses the first wave of SARS-CoV-2 transmission in the country. We estimate that the first wave of the SARS-CoV-2 pandemic peaked before the end of July 2020 in the major urban counties, with 30-50% of residents infected. Our analysis suggests, first, that the reported low COVID-19 disease burden in Kenya cannot be explained solely by limited spread of the virus, and second, that a 30-50% attack rate was not sufficient to avoid a further wave of transmission.

Background: There are limited studies in Africa describing the epidemiology, clinical characteristics and serostatus of individuals tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We tested routine samples from the Coastal part of Kenya between 17th March 2020 and 30th June 2021. Methods: SARS-CoV-2 infections identified using reverse transcription polymerase chain reaction (RT-PCR) and clinical surveillance data at the point of sample collection were used to classify as either symptomatic or asymptomatic. IgG antibodies were measured in sera samples, using a well validated in-house enzyme-linked immunosorbent assay (ELISA). Results: Mombasa accounted for 56.2% of all the 99,694 naso-pharyngeal/oro-pharyngeal swabs tested, and males constituted the majority tested (73.4%). A total of 7737 (7.7%) individuals were SARS-CoV-2 positive by RT-PCR. The majority (i.e., 92.4%) of the RT-PCR positive individuals were asymptomatic. Testing was dominated by mass screening and travellers, and even at health facility level 91.6% of tests were from individuals without symptoms. Out of the 97,124 tests from asymptomatic individuals 7,149 (7%) were positive and of the 2,568 symptomatic individuals 588 (23%) were positive. In total, 2458 serum samples were submitted with paired naso-pharyngeal/oro-pharyngeal samples and 45% of the RT-PCR positive samples and 20% of the RT-PCR negative samples were paired with positive serum samples. Symptomatic individuals had significantly higher antibody levels than asymptomatic individuals and become RT-PCR negative on repeat testing earlier than asymptomatic individuals. Conclusions: In conclusion, the majority of SARS-CoV-2 infections identified by routine testing in Coastal Kenya were asymptomatic. This reflects the testing practice of health services in Kenya, but also implies that asymptomatic infection is very common in the population. Symptomatic infection may be less common, or it may be that individuals do not present for testing when they have symptoms.

BackgroundMost of the studies that have informed the public health response to the COVID-19 pandemic in Kenya have relied on samples that are not representative of the general population. We conducted population-based serosurveys at three Health and Demographic Surveillance Systems (HDSSs) to determine the cumulative incidence of infection with SARS-CoV-2.MethodsWe selected random age-stratified population-based samples at HDSSs in Kisumu, Nairobi and Kilifi, in Kenya. Blood samples were collected from participants between 01 Dec 2020 and 27 May 2021. No participant had received a COVID-19 vaccine. We tested for IgG antibodies to SARS-CoV-2 spike protein using ELISA. Locally-validated assay sensitivity and specificity were 93% (95% CI 88-96%) and 99% (95% CI 98-99.5%), respectively. We adjusted prevalence estimates using classical methods and Bayesian modelling to account for the sampling scheme and assay performance.ResultsWe recruited 2,559 individuals from the three HDSS sites, median age (IQR) 27 (10-78) years and 52% were female. Seroprevalence at all three sites rose steadily during the study period. In Kisumu, Nairobi and Kilifi, seroprevalences (95% CI) at the beginning of the study were 36.0% (28.2-44.4%), 32.4% (23.1-42.4%), and 14.5% (9.1-21%), and respectively; at the end they were 42.0% (34.7-50.0%), 50.2% (39.7-61.1%), and 24.7% (17.5-32.6%), respectively. Seroprevalence was substantially lower among children (ConclusionBy May 2021 in three broadly representative populations of unvaccinated individuals in Kenya, seroprevalence of anti-SARS-CoV-2 IgG was 25-50%. There was wide variation in cumulative incidence by location and age.