Socioeconomic inequalities and inequities in the screening and treatment of diabetes and hypertension in Kenya

The burden of non-communicable diseases (NCDs) is on a disproportionate rise in low-and middleincome countries (LMICs). Equity in the utilisation of screening and treatment services for NCDs is important in reducing associated disease burden. For instance, the 2030 Sustainable Development Goal 3.4 that aims to reduce by one-third premature NCDs mortality, has adopted prevention and treatment as critical interventions for achieving this target. However, little is known about equity in the use of screening and treatment services for major NCDs like diabetes and hypertension in Kenya. This dissertation assesses horizontal equity (i.e. equal treatment for equal need) in the screening and treatment for diabetes and hypertension. Further, it examines factors contributing to inequality. Data from the 2015 STEPwise cross-sectional survey on NCDs risk factors were used in the analysis. Concentration curves, concentration indices and horizontal inequity index were used to assess socioeconomic inequality and inequity in the screening and treatment for diabetes and hypertension. The Wagstaff decomposition approach was used to examine factors contributing to socioeconomic inequality in screening and treatment. For a granular presentation of inequity and inequality findings, analyses were conducted across the wealth and regional divides in Kenya. Overall, the rich benefited disproportionately more in the utilisation of screening and treatment services, given their population share of need. Of note, inequalities in the use of screening and treatment interventions for diabetes and hypertension were observed in the geographic regions. In general, non-need factors such as educational attainment, area of residence, exposure to media, employment, and wealth status were the largest contributors to inequality in both screening and treatment. By contrast, need factors like sex also significantly contributed to inequality in diabetes and hypertension screening. After controlling for need, a statistically significant pro-rich inequity in the use of diabetes and hypertension screening was observed. Both the use of diabetes and hypertension treatment were pro-rich though a statistically significant result was only seen for the former. For equity in the screening and treatment for diabetes and hypertension in Kenya, demand enhancing mechanisms such as health education through the mass media and free NCD screening in the public sector should be implemented. Also, given the interplay of factors beyond the health sector that affect utilisation of healthcare services, there is a need for multi-sectoral approaches at various levels to address drivers of social inequality with a critical focus in rural and marginalised areas

Socioeconomic inequity in the screening and treatment of hypertension in Kenya: evidence from a national survey

Background: Non-communicable diseases (NCDs) account for 50% of hospitalisations and 55% of inpatient deaths in Kenya. Hypertension is one of the major NCDs in Kenya. Equitable access and utilisation of screening and treatment interventions are critical for reducing the burden of hypertension. This study assessed horizontal equity (equal treatment for equal need) in the screening and treatment for hypertension. It also decomposed socioeconomic inequalities in care use in Kenya. Methods: Cross-sectional data from the 2015 NCDs risk factors STEPwise survey, covering 4,500 adults aged 18–69 years were analysed. Socioeconomic inequality was assessed using concentration curves and concentration indices (CI), and inequity by the horizontal inequity (HI) index. A positive (negative) CI or HI value suggests a pro-rich (pro-poor) inequality or inequity. Socioeconomic inequality in screening and treatment for hypertension was decomposed into contributions of need [age, sex, and body mass index (BMI)] and non-need (wealth status, education, exposure to media, employment, and area of residence) factors using a standard decomposition method. Results: The need for hypertension screening was higher among poorer than wealthier socioeconomic groups (CI = −0.077; p < 0.05). However, wealthier groups needed hypertension treatment more than poorer groups (CI = 0.293; p <0.001). Inequity in the use of hypertension screening (HI = 0.185; p < 0.001) and treatment (HI = 0.095; p < 0.001) were significantly pro-rich. Need factors such as sex and BMI were the largest contributors to inequalities in the use of screening services. By contrast, non-need factors like the area of residence, wealth, and employment status mainly contributed to inequalities in the utilisation of treatment services. Conclusion: Among other things, the use of hypertension screening and treatment services in Kenya should be according to need to realise the Sustainable Development Goals for NCDs. Specifically, efforts to attain equity in healthcare use for hypertension services should be multi-sectoral and focused on crucial inequity drivers such as regional disparities in care use, poverty and educational attainment. Also, concerted awareness campaigns are needed to increase the uptake of screening services for hypertension

Evaluating the effectiveness of the National Health Insurance Fund in providing financial protection to households with hypertension and diabetes patients in Kenya.

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 < 0.001). Almost half (46.9%) of households reported active NHIF enrolment at baseline but this reduced to 10.9% after one year, indicating an NHIF attrition rate of 76.7%. The depth of NHIF cover (i.e., the share of out-of-pocket healthcare costs paid by NHIF) among households with active NHIF was 29.6%. CONCLUSION: We did not find strong evidence that the NHIF national scheme is effective in providing financial risk protection to households with individuals living with hypertension and/diabetes in Kenya. This could partly be explained by the low depth of cover of the NHIF national scheme, and the high attrition rate. To enhance NHIF effectiveness, there is a need to revise the NHIF benefit package to include essential hypertension and/diabetes services, review existing provider payment mechanisms to explicitly reimburse these services, and extend the existing insurance subsidy programme to include individuals in the informal labour market

Scaling up the primary health integrated care project for chronic conditions in Kenya: study protocol for an implementation research project.

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

Replication Data for: Patient costs of hypertension care in public healthcare facilities in Kenya

The dataset was used to estimate patients costs for seeking hypertension care in two counties in Keny

A bibliometric analysis of COVID-19 research in Africa

Background The COVID-19 pandemic has led to an unprecedented global research effort to build a body of knowledge that can inform mitigation strategies. We carried out a bibliometric analysis to describe the COVID-19 research output in Africa in terms of setting, study design, research themes and author affiliation.Methods We searched for articles published between 1 December 2019 and 3 January 2021 from various databases including PubMed, African Journals Online, medRxiv, Collabovid, the WHO global research database and Google. All article types and study design were included.Results A total of 1296 articles were retrieved. 46.6% were primary research articles, 48.6% were editorial-type articles while 4.6% were secondary research articles. 20.3% articles used the entire continent of Africa as their study setting while South Africa (15.4%) was the most common country-focused setting. The most common research topics include ‘country preparedness and response’ (24.9%) and ‘the direct and indirect health impacts of the pandemic’ (21.6%). However, only 1.0% of articles focus on therapeutics and vaccines. 90.3% of the articles had at least one African researcher as author, 78.5% had an African researcher as first author, while 63.5% had an African researcher as last author. The University of Cape Town leads with the greatest number of first and last authors. 13% of the articles were published in medRxiv and of the studies that declared funding, the Wellcome Trust was the top funding body.Conclusions This study highlights Africa’s COVID-19 research and the continent’s existing capacity to carry out research that addresses local problems. However, more studies focused on vaccines and therapeutics are needed to inform local development. In addition, the uneven distribution of research productivity among African countries emphasises the need for increased investment where needed

"We are called the et cetera": Experiences of the poor with health financing reforms that target them in Kenya

Background: Through a number of healthcare reforms, Kenya has demonstrated its intention to extend financial risk protection and service coverage for poor and vulnerable groups. These reforms include the provision of free maternity services, user-fee removal in public primary health facilities and a health insurance subsidy programme (HISP) for the poor. However, the available evidence points to inequity and the likelihood that the poor will still be left behind with regards to financial risk protection and service coverage. This study examined the experiences of the poor with health financing reforms that target them. Methods: We conducted a qualitative cross-sectional study in two purposively selected counties in Kenya. We collected data through focus group discussions (n = 8) and in-depth interviews (n = 30) with people in the lowest wealth quintile residing in the health and demographic surveillance systems, and HISP beneficiaries. We analyzed the data using a framework approach focusing on four healthcare access dimensions; geographical accessibility, affordability, availability, and acceptability. Results: Health financing reforms reduced financial barriers and improved access to health services for the poor in the study counties. However, various access barriers limited the extent to which they benefited from these reforms. Long distances, lack of public transport, poor condition of the roads and high transport costs especially in rural areas limited access to health facilities. Continued charging of user fees despite their abolition, delayed insurance reimbursements to health facilities that HISP beneficiaries were seeking care from, and informal fees exposed the poor to out of pocket payments. Stock-outs of medicine and other medical supplies, dysfunctional medical equipment, shortage of healthcare workers, and frequent strikes adversely affected the availability of health services. Acceptability of care was further limited by discrimination by healthcare workers and ineffective grievance redress mechanisms which led to a feeling of disempowerment among the poor. Conclusions: Pro-poor health financing reforms improved access to care for the poor to some extent. However, to enhance the effectiveness of pro-poor reforms and to ensure that the poor in Kenya benefit fully from them, there is a need to address barriers to healthcare seeking across all access dimensions

Completeness of malaria indicator data reporting via the District Health Information Software 2 in Kenya, 2011–2015

Abstract Background Health facility-based data reported through routine health information systems form the primary data source for programmatic monitoring and evaluation in most developing countries. The adoption of District Health Information Software (DHIS2) has contributed to improved availability of routine health facility-based data in many low-income countries. An assessment of malaria indicators data reported by health facilities in Kenya during the first 5 years of implementation of DHIS2, from January 2011 to December 2015, was conducted. Methods Data on 19 malaria indicators reported monthly by health facilities were extracted from the online Kenya DHIS2 database. Completeness of reporting was analysed for each of the 19 malaria indicators and expressed as the percentage of data values actually reported over the expected number; all health facilities were expected to report data for each indicator for all 12 months in a year. Results Malaria indicators data were analysed for 6235 public and 3143 private health facilities. Between 2011 and 2015, completeness of reporting in the public sector increased significantly for confirmed malaria cases across all age categories (26.5–41.9%, p < 0.0001, in children aged <5 years; 30.6–51.4%, p < 0.0001, in persons aged ≥5 years). Completeness of reporting of new antenatal care (ANC) clients increased from 53.7 to 70.5%, p < 0.0001). Completeness of reporting of intermittent preventive treatment in pregnancy (IPTp) decreased from 64.8 to 53.7%, p < 0.0001 for dose 1 and from 64.6 to 53.4%, p < 0.0001 for dose 2. Data on malaria tests performed and test results were not available in DHIS2 from 2011 to 2014. In 2015, sparse data on microscopy (11.5% for children aged <5 years; 11.8% for persons aged ≥5 years) and malaria rapid diagnostic tests (RDTs) (8.1% for all ages) were reported. In the private sector, completeness of reporting increased significantly for confirmed malaria cases across all age categories (16.7–23.1%, p < 0.0001, in children aged <5 years; 19.4–28.6%, p < 0.0001, in persons aged ≥5 years). Completeness of reporting also improved for new ANC clients (16.2–23.6%, p < 0.0001), and for IPTp doses 1 and 2 (16.6–20.2%, p < 0.0001 and 15.5–20.5%, p < 0.0001, respectively). In 2015, less than 3% of data values for malaria tests performed were reported in DHIS2 from the private sector. Conclusions There have been sustained improvements in the completeness of data reported for most key malaria indicators since the adoption of DHIS2 in Kenya in 2011. However, major data gaps were identified for the malaria-test indicator and overall low reporting across all indicators from private health facilities. A package of proven DHIS2 implementation interventions and performance-based incentives should be considered to improve private-sector data reporting

Patient costs of hypertension care in public health care facilities in Kenya

Background Hypertension in low‐ and middle‐income countries, including Kenya, is of economic importance due to its increasing prevalence and its potential to present an economic burden to households. In this study, we examined the patient costs associated with obtaining care for hypertension in public health care facilities in Kenya. Methods We conducted a cross‐sectional study among adult respondents above 18 years of age, with at least 6 months of treatment in two counties. A total of 212 patients seeking hypertension care at five public facilities were interviewed, and information on care seeking and the associated costs was obtained. We computed both annual direct and indirect costs borne by these patients. Results Overall, the mean annual direct cost to patients was US$304.8 (95$ 168.9; 95% CI, 132.5‐205.4), transport (mean annual cost, US$126.7; 95$ 57.7; 95% CI, 43.7‐71.6) were the highest direct cost categories. Overall mean annual indirect cost was US$ 171.7 (95% CI, 152.8‐190.5). The incidence of catastrophic health care costs was 43.3% (95% CI, 36.8‐50.2) and increased to 59.0% (95% CI, 52.2‐65.4) when transport costs were included. Conclusions Hypertensive patients incur substantial direct and indirect costs. High rates of catastrophic costs illustrate the urgency of improving financial risk protection for these patients and strengthening primary care to ensure affordability of hypertension care

Examining the responsiveness of the National Health Insurance Fund to people living with hypertension and diabetes in Kenya: a qualitative study

Objectives To assess the responsiveness of the National Health Insurance Fund (NHIF) Supa Cover benefit package to the needs of individuals with diabetes and hypertension in Kenya.Design, setting and participants We carried out a qualitative study and collected data using key informant interviews (n=39) and focus group discussions (n=4) in two purposively selected counties in Western Kenya. Study participants were drawn from NHIF officials, county government officials, health facility managers, healthcare workers and individuals with hypertension and diabetes who were enrolled in NHIF. We analysed data using a thematic approach.Results Study participants reported that the NHIF Supa Cover benefit package expanded access to services for people living with hypertension and diabetes. However, the NHIF members and healthcare workers had inadequate awareness of the NHIF service entitlements. The NHIF benefit package inadequately covered the range of services needed by people living with hypertension and diabetes and the benefits package did not prioritise preventive and promotive services. Sometimes patients were discriminated against by healthcare providers who preferred cash-paying patients, and some NHIF-empanelled health facilities had inadequate structural inputs essential for quality of care. Study participants felt that the NHIF premium for the general scheme was unaffordable, and NHIF members faced additional out-of-pocket costs because of additional payments for services not available or covered.Conclusion Whereas NHIF has reduced financial barriers for hypertension and diabetes patients, to enhance its responsiveness to patient needs, NHIF should implement mechanisms to increase benefit package awareness among members and providers. In addition, preventive and promotive services should be included in NHIF’s benefits package and mechanisms to monitor and hold contracted providers accountable should be strengthened