The COVID-19 pandemic and disruptions to essential health services in Kenya:A retrospective time-series analysis

Background: Public health emergencies can disrupt the provision of and access to essential health-care services, exacerbating health crises. We aimed to assess the effect of the COVID-19 pandemic on essential health-care services in Kenya. Methods: Using county-level data routinely collected from the health information system from health facilities across the country, we used a robust mixed-effect model to examine changes in 17 indicators of essential health services across four periods: the pre-pandemic period (from January, 2018 to February, 2020), two pandemic periods (from March to November 2020, and February to October, 2021), and the period during the COVID-19-associated health-care workers' strike (from December, 2020 to January, 2021). Findings: In the pre-pandemic period, we observed a positive trend for multiple indicators. The onset of the pandemic was associated with statistically significant decreases in multiple indicators, including outpatient visits (28·7%; 95% CI 16·0-43·5%), cervical cancer screening (49·8%; 20·6-57·9%), number of HIV tests conducted (45·3%; 23·9-63·0%), patients tested for malaria (31·9%; 16·7-46·7%), number of notified tuberculosis cases (26·6%; 14·7-45·1%), hypertension cases (10·4%; 6·0-39·4%), vitamin A supplements (8·7%; 7·9-10·5%), and three doses of the diphtheria, tetanus toxoid, and pertussis vaccine administered (0·9%; 0·5-1·3%). Pneumonia cases reduced by 50·6% (31·3-67·3%), diarrhoea by 39·7% (24·8-62·7%), and children attending welfare clinics by 39·6% (23·5-47·1%). Cases of sexual violence increased by 8·0% (4·3-25·0%). Skilled deliveries, antenatal care, people with HIV infection newly started on antiretroviral therapy, confirmed cases of malaria, and diabetes cases detected were not significantly affected negatively. Although most of the health indicators began to recover during the pandemic, the health-care workers' strike resulted in nearly all indicators falling to numbers lower than those observed at the onset or during the pre-strike pandemic period. Interpretation: The COVID-19 pandemic and the associated health-care workers' strike in Kenya have been associated with a substantial disruption of essential health services, with the use of outpatient visits, screening and diagnostic services, and child immunisation adversely affected. Efforts to maintain the provision of these essential health services during a health-care crisis should target the susceptible services to prevent the exacerbation of associated disease burdens during such health crises. Funding: Bill & Melinda Gates Foundation

Use of short text message reminders to improve attendance of postnatal care at a referral maternity hospital, Kenya, 2016—A randomised controlled trial

Introduction: Globally about 830 women die daily due to complications of pregnancy and child birth out of which 550 occur in Sub-Saharan Africa, with about 8,000 maternal deaths occurring annually in Kenya. 66% of maternal deaths occur within the first week and 85% of maternal deaths occur within two weeks post-delivery. Attendance of postnatal services during this time could significantly reduce morbidity and mortality. We determined effectiveness of short text message (SMS) in reducing failure-to-attend rates (FTA) of postnatal clinic at the largest maternity hospital in Nairobi, Kenya. Methods: We conducted a hospital-based randomised controlled trial. Women who delivered between March and May 2016 at Pumwani Maternity Hospital were recruited, enrolled and randomised into SMS (intervention) or no SMS (control) arms. Women were masked to which arm they belonged during randomisation but were unmasked during the appointments as the intervention had been sent. The investigators were not masked. Reminders were sent three days prior to and on the morning of the appointment. Relative Risk (RR) at 95% Confidence Interval were calculated to estimate the effectiveness of intervention at two and six-weeks. Results: We enrolled 754 women, with 377 randomly assigned into each arm. There were no differences in socio-demographic characteristics between the study arms at baseline. After two-weeks, women in the intervention arm had an 80% reduction in FTA risk (RR=0.2, 95% CI 0.1–0.3). After six weeks, women in the intervention arm had a 60% reduction in FTA risk (RR=0.4, 95% CI 0.2–0.6). Among participants, 80 (42.1%) women at two-weeks and 30 (41.7%) women at six-weeks cited forgetting appointment as the most common reason for failing to attend postnatal clinic. Conclusion: SMS reminders were effective in reducing failure-to-attend clinic appointments. We recommend the use of SMS reminder strategy for postnatal care

The COVID-19 pandemic and disruptions to essential health services in Kenya: a retrospective time-series analysis

Background: Public health emergencies can disrupt the provision of and access to essential health-care services, exacerbating health crises. We aimed to assess the effect of the COVID-19 pandemic on essential health-care services in Kenya. Methods: Using county-level data routinely collected from the health information system from health facilities across the country, we used a robust mixed-effect model to examine changes in 17 indicators of essential health services across four periods: the pre-pandemic period (from January, 2018 to February, 2020), two pandemic periods (from March to November 2020, and February to October, 2021), and the period during the COVID-19-associated health-care workers’ strike (from December, 2020 to January, 2021). Findings: In the pre-pandemic period, we observed a positive trend for multiple indicators. The onset of the pandemic was associated with statistically significant decreases in multiple indicators, including outpatient visits (28·7%; 95% CI 16·0–43·5%), cervical cancer screening (49·8%; 20·6–57·9%), number of HIV tests conducted (45·3%; 23·9–63·0%), patients tested for malaria (31·9%; 16·7–46·7%), number of notified tuberculosis cases (26·6%; 14·7–45·1%), hypertension cases (10·4%; 6·0–39·4%), vitamin A supplements (8·7%; 7·9–10·5%), and three doses of the diphtheria, tetanus toxoid, and pertussis vaccine administered (0·9%; 0·5–1·3%). Pneumonia cases reduced by 50·6% (31·3–67·3%), diarrhoea by 39·7% (24·8–62·7%), and children attending welfare clinics by 39·6% (23·5–47·1%). Cases of sexual violence increased by 8·0% (4·3–25·0%). Skilled deliveries, antenatal care, people with HIV infection newly started on antiretroviral therapy, confirmed cases of malaria, and diabetes cases detected were not significantly affected negatively. Although most of the health indicators began to recover during the pandemic, the health-care workers’ strike resulted in nearly all indicators falling to numbers lower than those observed at the onset or during the pre-strike pandemic period. Interpretation: The COVID-19 pandemic and the associated health-care workers’ strike in Kenya have been associated with a substantial disruption of essential health services, with the use of outpatient visits, screening and diagnostic services, and child immunisation adversely affected. Efforts to maintain the provision of these essential health services during a health-care crisis should target the susceptible services to prevent the exacerbation of associated disease burdens during such health crises

Distribution of HIV infected adults initiating combination antiretroviral therapy and eligible for the analysis using data from the national data warehouse in Kenya (2015HY2 to 2018HY1, N = 8592).

Distribution of HIV infected adults initiating combination antiretroviral therapy and eligible for the analysis using data from the national data warehouse in Kenya (2015HY2 to 2018HY1, N = 8592).</p

Effect of universal test-and-treat, defined as same day, 1–14 days, 15–90 days and 91+ days from a HIV diagnosis to combination antiretroviral therapy start, on initial virologic non-suppression (first available viral load test results of >400) amongst HIV infected adults starting combination antiretroviral therapy and captured in the national data warehouse in Kenya (2016-HY2 to 2018-HY1, N = 5986).

Effect of universal test-and-treat, defined as same day, 1–14 days, 15–90 days and 91+ days from a HIV diagnosis to combination antiretroviral therapy start, on initial virologic non-suppression (first available viral load test results of >400) amongst HIV infected adults starting combination antiretroviral therapy and captured in the national data warehouse in Kenya (2016-HY2 to 2018-HY1, N = 5986).</p

Factors associated with uptake of universal test-and-treat, defined as same-day HIV diagnosis and combination antiretroviral therapy start, amongst HIV infected adults using data from the national data warehouse in Kenya (2015HY2 to 2018HY1, N = 8592).

Factors associated with uptake of universal test-and-treat, defined as same-day HIV diagnosis and combination antiretroviral therapy start, amongst HIV infected adults using data from the national data warehouse in Kenya (2015HY2 to 2018HY1, N = 8592).</p

Factors associated with uptake of universal test and treat, defined as <14 days from HIV diagnosis and combination antiretroviral therapy start, amongst HIV infected adults using data from the national data warehouse in Kenya (2015-HY2 to 2018-HY1, N = 8592).

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Effect of universal test-and-treat uptake, defined as same day, 1–14 days, 15–90 days and 91+ days from a HIV diagnosis to combination antiretroviral therapy start on twelve months attrition, defined as lost to follow up or dead, amongst HIV infected adults captured in the national data warehouse in Kenya (2015HY2 to 2018HY1, N = 8592).

Effect of universal test-and-treat uptake, defined as same day, 1–14 days, 15–90 days and 91+ days from a HIV diagnosis to combination antiretroviral therapy start on twelve months attrition, defined as lost to follow up or dead, amongst HIV infected adults captured in the national data warehouse in Kenya (2015HY2 to 2018HY1, N = 8592).</p

Flow chart showing distribution of HIV infected individuals captured in the national data warehouse (NDW) and selection of eligible individuals carried forward to the analysis.

Flow chart showing distribution of HIV infected individuals captured in the national data warehouse (NDW) and selection of eligible individuals carried forward to the analysis.</p

An outline of facilities that met the eligibility criteria (lowest proportion missing date of HIV diagnosis and a viral load test done within 12 months of combination antiretroviral therapy initiation) from the 38 facilities from 38 counties contributing to the national data warehouse in Kenya and included in the analysis (2015-HY2 to 2018-HY1).

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