The introduction of new policies and strategies to reduce inequities and improve child health in Kenya: A country case study on progress in child survival, 2000-2013

As of 2015, only 12 countries in the World Health Organization’s AFRO region had met Millennium Development Goal #4 (MDG#4) to reduce under-five mortality by two-thirds by 2015. Given the variability across the African region, a four-country study was undertaken to examine barriers and facilitators of child survival prior to 2015. Kenya was one of the countries selected for an in-depth case study due to its insufficient progress in reducing under-five mortality, with only a 28% reduction between 1990 and 2013. This paper presents indicators, national documents, and qualitative data describing the factors that have both facilitated and hindered Kenya’s efforts in reducing child mortality. Key barriers identified in the data were widespread socioeconomic and geographic inequities in access and utilization of maternal, neonatal, and child health (MNCH) care. To reduce these inequities, Kenya implemented three major policies/strategies during the study period: removal of user fees, the Kenya Essential Package for Health, and the Community Health Strategy. This paper uses qualitative data and a policy review to explore the early impacts of these efforts. The removal of user fees has been unevenly implemented as patients still face hidden expenses. The Kenya Essential Package for Health has enabled construction and/or expansion of healthcare facilities in many areas, but facilities struggle to provide Emergency Obstetric and Neonatal Care (EmONC), neonatal care, and many essential medicines and commodities. The Community Health Strategy appears to have had the most impact, improving referrals from the community and provision of immunizations, malaria prevention, and Prevention of Mother-to-Child Transmission of HIV. However, the Community Health Strategy is limited by resources and thus also unevenly implemented in many areas. Although insufficient progress was made pre-2015, with additional resources and further scale-up of new policies and strategies Kenya can make further progress in child survival. The period of interest for this case study and the parent study on child survival in Africa was 2000–2013. Indicator data were obtained for years closest to 2000 and 2013 (details below), and national policies and strategies issued between 2000 and 2013 were also obtained. Key informant interviews and focus groups with community women occurred in 2013. The national document review, key informant interviews, and focus group discussions sought to explore the following eight content areas based on global strategies [22–27] related to child survival: 1) Health care system (including leadership, structure, human resources for health, access & utilization, monitoring & evaluation, and accountability), 2) National health strategies and policies (and regulations and laws, when applicable), 3) MNCH interventions, 4) Clinical standards and guidelines, 5) Commodities and essential medicines, 6) Financial flows and resources, 7) Effective partnerships, and 8) Other contextual factors (e.g., conflict, political environment, hygiene and sanitation, nutrition and food security, education, and human rights). Focus group discussions with community women focused only on the health care system, MNCH interventions, medicines, and contextual factors. Data were obtained on the core indicators monitored by Countdown to 2015. Most data were obtained from the World Bank Data Catalogue [28], a repository of national, regional, and global indicator data compiled from officially-recognized, international sources, including national Demographic and Health Surveys (DHS) and other surveys. While specific data sources differed from one indicator to another in the Data Catalogue, data sources and methods were consistent over time for any given indicator (see Kipp, et al. [21] for additional detail). Data for indicators not readily available from the World Bank Data Catalogue were obtained directly from the 1998 and 2014 Kenya DHS [29, 30]. Given the scope of the larger study within which this case study is nested and recognizing that indicator data are not always available for the exact years of interest, this study included those data that most closely corresponded to the beginning of the study period in 2000 (range 1998–2003) and end of the study period in 2013 (range 2009–2014). This enabled us to document the net change in coverage of key MNCH indicators by the end of the study period, relative to the beginning. An information abstraction guide was developed based on the general content areas listed above and the cross-cutting questions in Table 1. Policies and strategies pertaining to overall national health, MNCH, and those from other sectors related to MNCH (e.g., education, water and sanitation, and agriculture and nutrition) were obtained from the WHO African Region office, the WHO country focal points for Kenya, and Kenya’s Ministry of Health (MOH). These documents were reviewed and any additional documents referenced and deemed important were obtained from WHO or MOH. The final list of reviewed documents can be found in S1 Table. Each document was reviewed multiple times by one author (CAH) and a second reviewer (MAB) was consulted if further clarification on the document findings was needed. Information was recorded as outlined in the abstraction guide to standardize abstraction and summarization of content across documents. In order to avoid biased interpretation of the information documented, the abstracted information was reported as it was stated in the original source and efforts were made to avoid overstating or minimizing the original information or adding commentary not contained in the source. Because important differences in MNCH often exist between urban and rural areas, participants for the qualitative study were included from both urban and rural areas. Nairobi (Nairobi Province) was selected as the urban location and the areas surrounding Embu (Eastern Province) were chosen as a representative rural location. Both Nairobi and Eastern Provinces had under-five mortality ARRs comparable to the national ARR based on Kenya DHS data from 1993 [31] and 2008/09 [32]. Data were obtained from semi-structured, key informant interviews with Kenya MOH officials, donor partners, community-based organizations (CBO) involved in MNCH, and health care providers (HCP). Data were also obtained from four focus group discussions (two in Nairobi, two in Eastern Province) with 40 women who have experience accessing MNCH services for at least one child. Interviews and focus groups were conducted between October 6 and December 6, 2013. All participants, whether key informants or focus group women, were eligible for the study if they met the following criteria: 1) 18 years of age or older, 2) having adequate knowledge or experiences related to childhood survival specified for each participant group below, 3) English- or Swahili-speaking, and 4) being able to provide written or verbal informed consent. Specific inclusion criteria for each key informant group included the following: national or provincial-level officials working in government-level health care system administration, policy-making, program development, leadership, or any aspect of MNCH (MCDMCH officials); directors, managers, or other leaders of entities providing financial or other aid for MNCH services, or international or national organizations focusing on MNCH or with MNCH as one component of their mission (Donor organizations); directors, leaders, or managers working for a CBO involved in or providing referrals to MNCH services; and professionally trained physicians, nurses, clinical officers, or other health-related staff working in a health facility providing MNCH care (HCPs). For the FGDs, women with children (either living or deceased) aged five years old or younger who had sought MNCH services within the previous twelve months were purposefully sampled. Similar numbers of participants from each key informant group were enrolled, and a range of ages, work experiences, and positions/roles within each group was sought. Additionally, efforts were made to balance the number of urban and rural participants among the HCPs and CBO workers. Lists of potential key informants from each group were developed by the in-country research team with assistance, as needed, from the WHO focal points and an MOH official involved with Child and Adolescent Health. A letter signed by an official from the MOH was sent to each potential key informant participant informing them of the purpose of the study, risks and benefits of participation, and describing the interview process. These were followed-up with a phone call or email from the research team to set up a meeting time for those interested. Basic demographic characteristics of the key informants are shown in Table 2. *4 from international donor organizations, 4 from national organizations. **6 CBO participants from Nairobi (urban site), 2 from Embu; includes faith-based (3), private (3), and others with unstated affiliations (7). †7 from Nairobi (urban site), 6 from Embu; includes public/government hospital or clinic (11) and private, non-faith-based hospital (2). †† Other includes one each of Mijikenda and Taita, or not stated (n = 4) Women were recruited to participate in focus groups using snowball sampling. The research assistants also visited healthcare facilities to advertise the study. The two urban focus groups were held in Nairobi, one at a local hospital and one at a community center. The two rural focus groups were held at Embu County Hospital. Women were recruited primarily from the rural areas of Embu County; the hospital served as a familiar and central meeting location. For all focus groups, a multi-pronged approach was used for recruitment, including: a list of eligible women developed by community volunteers; snowball sampling in which eligible women were asked to refer their peers with children (living or deceased) aged five years old or younger; and advertising through the health facility. We did not ask healthcare providers or MoH officials for referrals to avoid bias. The FGDs were conducted by experienced social scientists who were aware of the possible effects the venue might have on interview dynamics, and the interviewers attempted to minimize this effect by conducting the FGDs outside of the hospital buildings. As with the key informants, a balance was sought in the level of education and the participants with live and deceased children, as well as a diversity of experiences and opinions regarding MNCH. All FGD participants were reimbursed for their time and travel at a maximum cost of 500 Kenyan Shillings (approximately 5 USD). Written informed consent was obtained from all enrolled participants. Basic demographic and health characteristics of the community women are shown in Table 3. * Other includes one Msukuma and one Arab Interview guides for key informants and discussion guides for focus groups with community women were developed, pilot tested through cognitive interviewing [33], and revised as needed. The guides focused on barriers and facilitators for improving child survival in areas related to MNCH, corresponding to the general content areas described above for the review of national health policies and strategies and the cross-cutting questions in Table 1. Not all topics were appropriate for each key informant group, but each topic was asked of at least two of the four groups. While participants were encouraged to discuss the entire period from 2000 forward, most participants recalled more recent information and experiences. Key informant interviews were conducted in English by one research assistant using the appropriate interview guide and were audio recorded. The focus groups were in Swahili and also audio recorded. Two research assistants were present at each focus group to facilitate discussion and note-taking. Audio recordings were transcribed by the research assistants, translated into English as needed, and field notes incorporated into the transcript. Transcripts were coded and analyzed using the qualitative software Atlas.ti [34]. Deductive themes were determined a priori based on interview guides and key topics of interest based on literature review. Additional themes were also identified upon review of the transcripts. Text was coded and reviewed for patterns of consistency, variation, relationships between themes and exemplary cases or quotations [35, 36]. Ethical approval for the qualitative portion of the study was obtained from the Kenyatta National Hospital/University of Nairobi Ethics and Research Council and from Vanderbilt University Medical Center Institutional Review Board.