Impact of COVID-19 on mortality in coastal Kenya: a longitudinal open cohort study

The mortality impact of COVID-19 in Africa remains controversial because most countries lack vital registration. We analysed excess mortality in Kilifi Health and Demographic Surveillance System, Kenya, using 9 years of baseline data. SARS-CoV-2 seroprevalence studies suggest most adults here were infected before May 2022. During 5 waves of COVID-19 (April 2020-May 2022) an overall excess mortality of 4.8% (95% PI 1.2%, 9.4%) concealed a significant excess (11.6%, 95% PI 5.9%, 18.9%) among older adults ( ≥ 65 years) and a deficit among children aged 1–14 years (−7.7%, 95% PI −20.9%, 6.9%). The excess mortality rate for January 2020-December 2021, age-standardised to the Kenyan population, was 27.4/100,000 person-years (95% CI 23.2-31.6). In Coastal Kenya, excess mortality during the pandemic was substantially lower than in most high-income countries but the significant excess mortality in older adults emphasizes the value of achieving high vaccine coverage in this risk group

A Multifaceted Intervention to Improve the Quality of Care of Children in District Hospitals in Kenya: A Cost-Effectiveness Analysis

A cost-effective analysis conducted by Edwine Barasa and colleagues estimates that a complex intervention aimed at improving quality of pediatric care would be affordable and cost-effective in Kenya

Using health worker opinions to assess changes in structural components of quality in a Cluster Randomized Trial.

BACKGROUND: The 'resource readiness' of health facilities to provide effective services is captured in the structure component of the classical Donabedian paradigm often used for assessment of the quality of care in the health sector. Periodic inventories are commonly used to confirm the presence (or absence) of equipment or drugs by physical observation or by asking those in charge to indicate whether an item is present or not. It is then assumed that this point observation is representative of the everyday status. However the availability of an item (consumables) may vary. Arguably therefore a more useful assessment for resources would be one that captures this fluctuation in time. Here we report an approach that may circumvent these difficulties. METHODS: We used self-administered questionnaires (SAQ) to seek health worker views of availability of key resources supporting paediatric care linked to a cluster randomized trial of a multifaceted intervention aimed at improving this care conducted in eight rural Kenyan district hospitals. Four hospitals received a full intervention and four a partial intervention. Data were collected pre-intervention and after 6 and 18 months from health workers in three clinical areas asked to score item availability using an 11-point scale. Mean scores for items common to all 3 areas and mean scores for items allocated to domains identified using exploratory factor analysis (EFA) were used to describe availability and explore changes over time. RESULTS: SAQ were collected from 1,156 health workers. EFA identified 11 item domains across the three departments. Mean availability scores for these domains were often <5/10 at baseline reflecting lack of basic resources such as oxygen, nutrition and second line drugs. An improvement in mean scores occurred in 8 out of 11 domains in both control and intervention groups. A calculation of difference in difference of means for intervention vs. control suggested an intervention effect resulting in greater changes in 5 out of 11 domains. CONCLUSION: Using SAQ data to assess resource availability experienced by health workers provides an alternative to direct observations that provide point prevalence estimates. Further the approach was able to demonstrate poor access to resources, change over time and variability across place

Examining levels, distribution and correlates of health insurance coverage in Kenya

OBJECTIVE:To examine the levels, inequalities and factors associated with health insurance coverage in Kenya. METHODS:We analysed secondary data from the Kenya Demographic and Health Survey (KDHS) conducted in 2009 and 2014. We examined the level of health insurance coverage overall, and by type, using an asset index to categorise households into five socio-economic quintiles with quintile 5 (Q5) being the richest and quintile 1 (Q1) being the poorest. The high-low ratio (Q5/Q1 ratio), concentration curve and concentration index (CIX) were employed to assess inequalities in health insurance coverage, and logistic regression to examine correlates of health insurance coverage. RESULTS:Overall health insurance coverage increased from 8.17% to 19.59% between 2009 and 2014. There was high inequality in overall health insurance coverage, even though this inequality decreased between 2009 (Q5/Q1 ratio of 31.21, CIX = 0.61, 95% CI 0.52-0.0.71) and 2014 (Q5/Q1 ratio 12.34, CIX = 0.49, 95% CI 0.45-0.52). Individuals that were older, employed in the formal sector; married, exposed to media; and male, belonged to a small household, had a chronic disease and belonged to rich households, had increased odds of health insurance coverage. CONCLUSION:Health insurance coverage in Kenya remains low and is characterised by significant inequality. In a context where over 80% of the population is in the informal sector, and close to 50% live below the national poverty line, achieving high and equitable coverage levels with contributory and voluntary health insurance mechanism is problematic. Kenya should consider a universal, tax-funded mechanism that ensures revenues are equitably and efficiently collected, and everyone (including the poor and those in the informal sector) is covered

Viewpoint: Economic evaluation of package of care interventions employing clinical guidelines.

Increasingly attention is shifting towards delivering essential packages of care, often based on clinical practice guidelines, as a means to improve maternal, child and newborn survival in low-income settings. Cost effectiveness analysis (CEA), allied to the evaluation of less complex intervention, has become an increasingly important tool for priority setting. Arguably such analyses should be extended to inform decisions around the deployment of more complex interventions. In the discussion, we illustrate some of the challenges facing the extension of CEA to this area. We suggest that there are both practical and methodological challenges to overcome when conducting economic evaluation for packages of care interventions that incorporate clinical guidelines. Some might be overcome by developing specific guidance on approaches, for example clarity in identifying relevant costs. Some require consensus on methods. The greatest challenge, however, lies in how to incorporate, as measures of effectiveness, process measures of service quality. Questions on which measures to use, how multiple measures might be combined, how improvements in one area might be compared with those in another and what value is associated with improvement in health worker practices are yet to be answered

Assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in Kenya

BACKGROUND:Monitoring the incidence and intensity of catastrophic health expenditure, as well as the impoverishing effects of out of pocket costs to access healthcare, is a key part of benchmarking Kenya's progress towards reducing the financial burden that households experience when accessing healthcare. METHODS:The study relies on data from the nationally-representative Kenya Household Expenditure and Utilization Survey conducted in 2013 (n =33,675). We undertook health equity analysis to estimate the incidence and intensity of catastrophic expenditure. Households were considered to have incurred catastrophic expenditures if their annual out of-pocket health expenditures exceeded 40% of their annual non-food expenditure. We assessed the impoverishing effects of out of pocket payments using the Kenya national poverty line. We distinguished between direct payments for healthcare such as payments for consultation, medicines, medical procedures, and total healthcare expenditure that includes direct healthcare payments and the cost of transportation to and from health facilities. We used logistic regression analysis to explore the factors associated with the incidence of catastrophic expenditures. RESULTS:When only direct payments to healthcare providers were considered, the incidence of catastrophic expenditures was 4.52%. When transport costs are included, the incidence of catastrophic expenditure increased to 6.58%. 453,470 Kenyans are pushed into poverty annually as a result of direct payments for healthcare. When the cost of transport is included, that number increases by more than one third to 619,541. Unemployment of the household head, presence of an elderly person, a person with a chronic ailment, a large household size, lower household social-economic status, and residence in marginalized regions of the country are significantly associated with increased odds of incurring catastrophic expenditures. CONCLUSIONS:Kenyan policy makers should prioritize extending pre-payment mechanisms to more vulnerable groups, specifically the poor, the elderly, those suffering from chronic ailments and those living in marginalized regions of the country. The range of services covered under these mechanisms should also be extended such that the proportion of direct costs paid to access care is reduced. Policy makers should also prioritize reducing supply side bottlenecks such as availability of healthcare facilities in close proximity to the population, especially in rural and marginalized areas, and improvements in quality of care. For the poor and the vulnerable, initiatives to cover the cost of transport to and from a health facility, such as transport vouchers could also be explored

From bouncing back, to nurturing emergence: reframing the concept of resilience in health systems strengthening

Recent health system shocks such as the Ebola disease outbreak have focused global health attention on the notion of resilient health systems. In this commentary, we reflect on the current framing of the concept of resilience in health systems discourse and propose a reframing. Specifically, we propose that: (1) in addition to sudden shocks, health systems face the ongoing strain of multiple factors. Health systems need the capacity to continue to deliver services of good quality and respond effectively to wider health challenges. We call this capacity everyday resilience; (2) health system resilience entails more than bouncing back from shock. In complex adaptive systems (CAS), resilience emerges from a combination of absorptive, adaptive and transformative strategies; (3) nurturing the resilience of health systems requires understanding health systems as comprising not only hardware elements (such as finances and infrastructure), but also software elements (such as leadership capacity, power relations, values and appropriate organizational culture). We also reflect on current criticisms of the concept of resilient health systems, such as that it assumes that systems are apolitical, ignoring actor agency, promoting inaction, and requiring that we accept and embrace vulnerability, rather than strive for stronger and more responsive systems. We observe that these criticisms are warranted to the extent that they refer to notions of resilience that are mismatched with the reality of health systems as CAS. We argue that the observed weaknesses of resilience thinking can be addressed by reframing and applying a resilience lens that is better suited to the attributes of health systems as CAS

From bouncing back, to nurturing emergence: reframing the concept of resilience in health systems strengthening

Recent health system shocks such as the Ebola disease outbreak have focused global health attention on the notion of resilient health systems. In this commentary, we reflect on the current framing of the concept of resilience in health systems discourse and propose a reframing. Specifically, we propose that: (1) in addition to sudden shocks, health systems face the ongoing strain of multiple factors. Health systems need the capacity to continue to deliver services of good quality and respond effectively to wider health challenges. We call this capacity everyday resilience; (2) health system resilience entails more than bouncing back from shock. In complex adaptive systems (CAS), resilience emerges from a combination of absorptive, adaptive and transformative strategies; (3) nurturing the resilience of health systems requires understanding health systems as comprising not only hardware elements (such as finances and infrastructure), but also software elements (such as leadership capacity, power relations, values and appropriate organizational culture). We also reflect on current criticisms of the concept of resilient health systems, such as that it assumes that systems are apolitical, ignoring actor agency, promoting inaction, and requiring that we accept and embrace vulnerability, rather than strive for stronger and more responsive systems. We observe that these criticisms are warranted to the extent that they refer to notions of resilience that are mismatched with the reality of health systems as CAS. We argue that the observed weaknesses of resilience thinking can be addressed by reframing and applying a resilience lens that is better suited to the attributes of health systems as CAS