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Papers by Helen Kiarie

Research paper thumbnail of Policies and resources for strengthening of emergency and critical care services in the context of the global COVID-19 pandemic in Kenya

PLOS Global Public Health

Critical illnesses cause several million deaths annually, with many of these occurring in low-res... more Critical illnesses cause several million deaths annually, with many of these occurring in low-resource settings like Kenya. Great efforts have been made worldwide to scale up critical care to reduce deaths from COVID-19. Lower income countries with fragile health systems may not have had sufficient resources to upscale their critical care. We aimed to review how efforts to strengthen emergency and critical care were operationalised during the pandemic in Kenya to point towards how future emergencies should be approached. This was an exploratory study that involved document reviews, and discussions with key stakeholders (donors, international agencies, professional associations, government actors), during the first year of the pandemic in Kenya. Our findings suggest that pre-pandemic health services for the critically ill in Kenya were sparse and unable to meet rising demand, with major limitations noted in human resources and infrastructure. The pandemic response saw galvanised acti...

Research paper thumbnail of Healthcare utilization and maternal and child mortality during the COVID-19 pandemic in 18 low- and middle-income countries: An interrupted time-series analysis with mathematical modeling of administrative data

PLOS Medicine

Background The Coronavirus Disease 2019 (COVID-19) pandemic has had wide-reaching direct and indi... more Background The Coronavirus Disease 2019 (COVID-19) pandemic has had wide-reaching direct and indirect impacts on population health. In low- and middle-income countries, these impacts can halt progress toward reducing maternal and child mortality. This study estimates changes in health services utilization during the pandemic and the associated consequences for maternal, neonatal, and child mortality. Methods and findings Data on service utilization from January 2018 to June 2021 were extracted from health management information systems of 18 low- and lower-middle-income countries (Afghanistan, Bangladesh, Cameroon, Democratic Republic of the Congo (DRC), Ethiopia, Ghana, Guinea, Haiti, Kenya, Liberia, Madagascar, Malawi, Mali, Nigeria, Senegal, Sierra Leone, Somalia, and Uganda). An interrupted time-series design was used to estimate the percent change in the volumes of outpatient consultations and maternal and child health services delivered during the pandemic compared to projecte...

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

The Lancet Global Health

Background Public health emergencies can disrupt the provision of and access to essential health-... more 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.

Research paper thumbnail of Characterising Kenyan hospitals’ suitability for medical officer internship training: a secondary data analysis of a cross-sectional study

BMJ Open

ObjectiveTo characterise the capacity of Kenya internship hospitals to understand whether they ar... more ObjectiveTo characterise the capacity of Kenya internship hospitals to understand whether they are suitable to provide internship training for medical doctors.DesignA secondary data analysis of a cross-sectional health facility assessment (Kenya Harmonized Health Facility Assessment (KHFA) 2018).Setting and populationWe analysed 61 out of all 74 Kenyan hospitals that provide internship training for medical doctors.Outcome measuresComparing against the minimum requirement outlined in the national guidelines for medical officer interns, we filtered and identified 166 indicators from the KHFA survey questionnaire and grouped them into 12 domains. An overall capacity index was calculated as the mean of 12 domain-specific scores for each facility.ResultsThe average overall capacity index is 69% (95% CI 66% to 72%) for all internship training centres. Hospitals have moderate capacity (over 60%) for most of the general domains, although there is huge variation between hospitals and only 29...

Research paper thumbnail of Characterising hospitals’ suitability for medical officer internship training in Kenya: analysis of the Kenya Harmonized Health Facility Assessment

Background Kenya has significantly expanded its medical school numbers and internship training ho... more Background Kenya has significantly expanded its medical school numbers and internship training hospital numbers to address its workforce gap. The majority of newly accredited internship hospitals are first-level referral/district hospitals, which are considered to have shortage of staff, medications, have limited service capacity and are described as “not organized for training purpose”. Using data from the Kenya Harmonized Health Facility Assessment (KHFA) 2018, we characterise the readiness and capacity of 61 internship hospitals to understand whether they are suitable to provide internship training for medical doctors. Methods We used secondary data from KHFA 2018, which sampled 61 out of all 74 internship hospitals in Kenya. Comparing against the minimum requirement outlined in the national guidelines for medical officer interns, we filtered and identified 166 indicators from the KHFA survey questionnaire and grouped them into 12 domains. An overall readiness and capacity index ...

Research paper thumbnail of Indirect Effects on Maternal and Child Mortality from the COVID-19 Pandemic: Evidence from Disruptions in Healthcare Utilization in 18 Low- and Middle-Income Countries

SSRN Electronic Journal, 2021

Background: The COVID-19 pandemic has had wide-reaching direct and indirect impacts on population... more Background: The COVID-19 pandemic has had wide-reaching direct and indirect impacts on population health. We describe one of the most critical of these secondary consequences, the decrease in the utilization of health services and the resulting consequences for mortality. In low- and middle-income countries, these disruptions can halt progress towards reducing maternal and child mortality.Methods: Data on service utilization from January 2018 to June 2021 is extracted from health management information systems of 18 low- and lower-middle-income countries. Interrupted time series design is used to estimate percent change in the volumes of essential health services delivered during the pandemic compared to projected volumes based on pre-pandemic trends. The Lives Saved Tool mathematical model is used to estimate the impact of the service utilization disruptions on child and maternal mortality. In addition, the estimated monthly disruptions are also correlated to the COVID-19 burden, time since the start of the pandemic, and relative severity of mobility restrictions.Findings: We estimate that decreases in essential health service utilization between March 2020 and June 2021 led to 113,873 additional deaths in the 18 countries, representing 3.8% and 1.4% increases in child and maternal mortality, respectively. This corresponds to an average of 2.6 indirect deaths per COVID-19 death officially reported in the same period. This excess mortality results from the decline in utilization of the RMNCH services included in the analysis, but the utilization shortfalls vary substantially between countries, health services, and over time. The largest disruptions, resulting in 27.5% of the excess death, occurred during the second quarter of 2020, regardless of whether countries experienced the highest rate of COVID-19-related deaths during the same months. There is a significant relationship between the magnitude of service disruptions and the stringency of mobility restrictions. Interpretation: Large declines in health care utilization during the COVID-19 pandemic amplify the pandemic's harmful impacts on health outcomes. As efforts and resource allocation towards prevention and treatment of COVID-19 continue, essential health services must be maintained, particularly in low and middle-income countries.Funding: The Global Financing Facility for Women, Children, and Adolescents.Declaration of Interests: We declare no competing interests.

Research paper thumbnail of Annual Primary Care 2030 Convening: Creating an Enabling Ecosystem for Person-Centered Primary Healthcare Models to Achieve Universal Health Coverage in Low- and Middle-Income Countries

Annals of Global Health, 2020

reaffirm the highest level of political commitment by United Nations Member States to achieve acc... more reaffirm the highest level of political commitment by United Nations Member States to achieve access to health services and primary healthcare for all. Both documents emphasize the importance of person-centered care in both healthcare services and systems design. However, there is limited consensus on how to build a strong primary healthcare system to achieve these goals. Methods: We convened a diverse group of global stakeholders for a high-level dialogue on how to create a person-centered primary healthcare system, using the country examples of the Republic of Kenya and the Socialist Republic of Vietnam. We focused our discussion on four themes to enable the creation of personcentered primary healthcare systems in Kenya and Vietnam: (1) strengthened community, person and patient engagement in subnational and national decision making; (2) improved service delivery; (3) impactful use of innovation and technology; and (4) meaningful and timely use of measurement and data. Findings: Here, we present a summary of our convening's proceedings, with specific insights on how to enable a person-centered primary healthcare system within each of these four domains. Conclusions: Following the 2019 United Nations General Assembly High-Level Meeting on Universal Health Coverage and the 2018 Declaration of Astana, there is high-level commitment and global consensus that a person-centered approach is necessary to achieve high-quality primary healthcare and universal health coverage. We offer our recommendations to the global community to catalyze further discourse and inform policy-making and program development on the path to Universal Health Coverage by 2030.

Research paper thumbnail of COVID-19 Pandemic and Disruptions in Essential Health Services in Kenya

SSRN Electronic Journal, 2021

Background: Public health emergencies can disrupt provision and access of essential healthcare se... more Background: Public health emergencies can disrupt provision and access of essential healthcare services, exacerbating the health crisis. We assessed the effect of COVID-19 pandemic on essential healthcare services in Kenya, and how those varied with the burden of COVID-19 in different regions of the country. Methods: Using data routinely collected from health facilities across the country, we conducted interrupted time series analysis to examine the impact of COVID-19 on key indicators of essential healthcare. We fitted the models using the data from the pre-pandemic period, predicted the trends for the next 13 months for each indicator, and compared the predicted values with the observed cases during the pandemic period. We used Poisson models to estimate the monthly incident rate ratios for each indicator to compare the effect in regions with high and low COVID-19 burden. Findings: Outpatients visits declined by 21% during the pandemic, with children <5years and regions with higher COVID-19 cases more severely affected. Vaccinations against childhood illnesses, attendance to welfare clinics, screening for cervical cancer declined with largest declines observed during COVID-19 movement restrictions. Cases of sexual violence and diabetes increased, while those of pneumonia and diarrhoea decreased. Antenatal clinic visits, number of skilled deliveries, children receiving Vitamin A supplements remained unchanged. Interpretation: The COVID-19 pandemic in Kenya disrupted essential health services with utilization of outpatient visits, child immunization, screening and diagnostic services adversely affected. There is need for attention on these vulnerable essential services to prevent exacerbation of associated disease burdens during health crises. Funding Information: Centre for Epidemiological and Modelling Analysis, University of Nairobi receives support from Bill and Melinda Gates Foundation. Declaration of Interests: None to declare.

Research paper thumbnail of Predictors of adherance to HAART in Mbagathi district hospital

Background Adherence to highly active antiretroviral therapy (HAART) medications is critically im... more Background Adherence to highly active antiretroviral therapy (HAART) medications is critically important for the success of therapy in patients treated for Human Immunodeficiency virus Acquired Immunodeficiency Syndrome (HIV/AIDS). Successful long-term treatment of HIV/AIDS requires at least 95% adherence to HAART, which, based on a twice a day regimen, translates into missing no more than two doses per month. This high level of adherence is necessary to prevent emergence of drug-resistant HIV variants that lead to regimen failure, and limit options for future therapy. Several factors have been described in various settings as being associated with adherence. These are Psycho-Socio Support, Time on ART, Financial support, Psychosocial and Antiretroviral side effects. Patient factors have been found to be the most important predictors of adherence in most studies. The impact of unpunctuality for clinic appointments is closely associated with treatment outcomes for HAART. Virologic fa...

Research paper thumbnail of Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017

The Lancet, 2018

Background Efforts to establish the 2015 baseline and monitor early implementation of the UN Sust... more Background Efforts to establish the 2015 baseline and monitor early implementation of the UN Sustainable Development Goals (SDGs) highlight both great potential for and threats to improving health by 2030. To fully deliver on the SDG aim of "leaving no one behind", it is increasingly important to examine the health-related SDGs beyond national-level estimates. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017), we measured progress on 41 of 52 health-related SDG indicators and estimated the health-related SDG index for 195 countries and territories for the period 1990-2017, projected indicators to 2030, and analysed global attainment. Methods We measured progress on 41 health-related SDG indicators from 1990 to 2017, an increase of four indicators since GBD 2016 (new indicators were health worker density, sexual violence by non-intimate partners, population census status, and prevalence of physical and sexual violence [reported separately]). We also improved the measurement of several previously reported indicators. We constructed national-level estimates and, for a subset of health-related SDGs, examined indicator-level differences by sex and Socio-demographic Index (SDI) quintile. We also did subnational assessments of performance for selected countries. To construct the healthrelated SDG index, we transformed the value for each indicator on a scale of 0-100, with 0 as the 2•5th percentile and 100 as the 97•5th percentile of 1000 draws calculated from 1990 to 2030, and took the geometric mean of the scaled indicators by target. To generate projections through 2030, we used a forecasting framework that drew estimates from the broader GBD study and used weighted averages of indicator-specific and country-specific annualised rates of change from 1990 to 2017 to inform future estimates. We assessed attainment of indicators with defined targets in two ways: first, using mean values projected for 2030, and then using the probability of attainment in 2030 calculated from 1000 draws. We also did a global attainment analysis of the feasibility of attaining SDG targets on the basis of past trends. Using 2015 global averages of indicators with defined SDG targets, we calculated the global annualised rates of change required from 2015 to 2030 to meet these targets, and then identified in what percentiles the required global annualised rates of change fell in the distribution of country-level rates of change from 1990 to 2015. We took the mean of these global percentile values across indicators and applied the past rate of change at this mean global percentile to all health-related SDG indicators, irrespective of target definition, to estimate the equivalent 2030 global average value and percentage change from 2015 to 2030 for each indicator. Findings The global median health-related SDG index in 2017 was 59•4 (IQR 35•4-67•3), ranging from a low of 11•6 (95% uncertainty interval 9•6-14•0) to a high of 84•9 (83•1-86•7). SDG index values in countries assessed at the subnational level varied substantially, particularly in China and India, although scores in Japan and the UK were more homogeneous. Indicators also varied by SDI quintile and sex, with males having worse outcomes than females for non-communicable disease (NCD) mortality, alcohol use, and smoking, among others. Most countries were projected to have a higher health-related SDG index in 2030 than in 2017, while country-level probabilities of attainment by 2030 varied widely by indicator. Under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria indicators had the most countries with at least 95% probability of target attainment. Other indicators, including NCD mortality and suicide mortality, had no countries projected to meet corresponding SDG targets on the basis of projected mean values for 2030 but showed some probability of attainment by 2030. For some indicators, including child malnutrition, several infectious diseases, and most violence measures, the annualised rates of change required to meet SDG targets far exceeded the pace of progress achieved by any country in the recent past. We found that applying the mean global annualised rate of change to indicators without defined targets would equate to about 19% and 22% reductions in global smoking and alcohol consumption, respectively; a 47% decline in adolescent birth rates; and a more than 85% increase in health worker density per 1000 population by 2030.

Research paper thumbnail of Health service utilisation during the COVID-19 pandemic in sub-Saharan Africa in 2020: a multicountry empirical assessment with a focus on maternal, newborn and child health services

BMJ Global Health

IntroductionThere are concerns about the impact of the COVID-19 pandemic on the continuation of e... more IntroductionThere are concerns about the impact of the COVID-19 pandemic on the continuation of essential health services in sub-Saharan Africa. Through the Countdown to 2030 for Women’s, Children’s and Adolescents’ Health country collaborations, analysts from country and global public health institutions and ministries of health assessed the trends in selected services for maternal, newborn and child health, general service utilisation.MethodsMonthly routine health facility data by district for the period 2017–2020 were compiled by 12 country teams and adjusted after extensive quality assessments. Mixed effects linear regressions were used to estimate the size of any change in service utilisation for each month from March to December 2020 and for the whole COVID-19 period in 2020.ResultsThe completeness of reporting of health facilities was high in 2020 (median of 12 countries, 96% national and 91% of districts ≥90%), higher than in the preceding years and extreme outliers were few...

Research paper thumbnail of Health disparities across the counties of Kenya and implications for policy makers, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

The Lancet Global Health, 2019

Kenya has made progress in tackling various health challenges, particularly those linked to prior... more Kenya has made progress in tackling various health challenges, particularly those linked to priority communicable diseases. 7,8 Declines in diarrhoea, lower respiratory infections, and vaccine-preventable diseases have occurred alongside decreasing maternal and neonatal mortality, although mortality rates remain comparatively high and unequal across counties. 7,9,10 The Kenya Expanded Programme on Immunization endorses childhood vaccination for tuberculosis, polio, diphtheria, whooping cough, tetanus, measles, hepatitis B, Haemophilus influenzae type b, pneumococcus, and rotavirus. 11 Kenya has among the highest rates of HIV/AIDS and tuberculosis in the world, although mortality rates have declined since the early 2000s, particularly for HIV/AIDS. 12,13 Malaria mortality in children declined substantially between 2003 and 2007, 14,15 although reports indicate increasing incidence

Research paper thumbnail of Policies and resources for strengthening of emergency and critical care services in the context of the global COVID-19 pandemic in Kenya

PLOS Global Public Health

Critical illnesses cause several million deaths annually, with many of these occurring in low-res... more Critical illnesses cause several million deaths annually, with many of these occurring in low-resource settings like Kenya. Great efforts have been made worldwide to scale up critical care to reduce deaths from COVID-19. Lower income countries with fragile health systems may not have had sufficient resources to upscale their critical care. We aimed to review how efforts to strengthen emergency and critical care were operationalised during the pandemic in Kenya to point towards how future emergencies should be approached. This was an exploratory study that involved document reviews, and discussions with key stakeholders (donors, international agencies, professional associations, government actors), during the first year of the pandemic in Kenya. Our findings suggest that pre-pandemic health services for the critically ill in Kenya were sparse and unable to meet rising demand, with major limitations noted in human resources and infrastructure. The pandemic response saw galvanised acti...

Research paper thumbnail of Healthcare utilization and maternal and child mortality during the COVID-19 pandemic in 18 low- and middle-income countries: An interrupted time-series analysis with mathematical modeling of administrative data

PLOS Medicine

Background The Coronavirus Disease 2019 (COVID-19) pandemic has had wide-reaching direct and indi... more Background The Coronavirus Disease 2019 (COVID-19) pandemic has had wide-reaching direct and indirect impacts on population health. In low- and middle-income countries, these impacts can halt progress toward reducing maternal and child mortality. This study estimates changes in health services utilization during the pandemic and the associated consequences for maternal, neonatal, and child mortality. Methods and findings Data on service utilization from January 2018 to June 2021 were extracted from health management information systems of 18 low- and lower-middle-income countries (Afghanistan, Bangladesh, Cameroon, Democratic Republic of the Congo (DRC), Ethiopia, Ghana, Guinea, Haiti, Kenya, Liberia, Madagascar, Malawi, Mali, Nigeria, Senegal, Sierra Leone, Somalia, and Uganda). An interrupted time-series design was used to estimate the percent change in the volumes of outpatient consultations and maternal and child health services delivered during the pandemic compared to projecte...

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

The Lancet Global Health

Background Public health emergencies can disrupt the provision of and access to essential health-... more 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.

Research paper thumbnail of Characterising Kenyan hospitals’ suitability for medical officer internship training: a secondary data analysis of a cross-sectional study

BMJ Open

ObjectiveTo characterise the capacity of Kenya internship hospitals to understand whether they ar... more ObjectiveTo characterise the capacity of Kenya internship hospitals to understand whether they are suitable to provide internship training for medical doctors.DesignA secondary data analysis of a cross-sectional health facility assessment (Kenya Harmonized Health Facility Assessment (KHFA) 2018).Setting and populationWe analysed 61 out of all 74 Kenyan hospitals that provide internship training for medical doctors.Outcome measuresComparing against the minimum requirement outlined in the national guidelines for medical officer interns, we filtered and identified 166 indicators from the KHFA survey questionnaire and grouped them into 12 domains. An overall capacity index was calculated as the mean of 12 domain-specific scores for each facility.ResultsThe average overall capacity index is 69% (95% CI 66% to 72%) for all internship training centres. Hospitals have moderate capacity (over 60%) for most of the general domains, although there is huge variation between hospitals and only 29...

Research paper thumbnail of Characterising hospitals’ suitability for medical officer internship training in Kenya: analysis of the Kenya Harmonized Health Facility Assessment

Background Kenya has significantly expanded its medical school numbers and internship training ho... more Background Kenya has significantly expanded its medical school numbers and internship training hospital numbers to address its workforce gap. The majority of newly accredited internship hospitals are first-level referral/district hospitals, which are considered to have shortage of staff, medications, have limited service capacity and are described as “not organized for training purpose”. Using data from the Kenya Harmonized Health Facility Assessment (KHFA) 2018, we characterise the readiness and capacity of 61 internship hospitals to understand whether they are suitable to provide internship training for medical doctors. Methods We used secondary data from KHFA 2018, which sampled 61 out of all 74 internship hospitals in Kenya. Comparing against the minimum requirement outlined in the national guidelines for medical officer interns, we filtered and identified 166 indicators from the KHFA survey questionnaire and grouped them into 12 domains. An overall readiness and capacity index ...

Research paper thumbnail of Indirect Effects on Maternal and Child Mortality from the COVID-19 Pandemic: Evidence from Disruptions in Healthcare Utilization in 18 Low- and Middle-Income Countries

SSRN Electronic Journal, 2021

Background: The COVID-19 pandemic has had wide-reaching direct and indirect impacts on population... more Background: The COVID-19 pandemic has had wide-reaching direct and indirect impacts on population health. We describe one of the most critical of these secondary consequences, the decrease in the utilization of health services and the resulting consequences for mortality. In low- and middle-income countries, these disruptions can halt progress towards reducing maternal and child mortality.Methods: Data on service utilization from January 2018 to June 2021 is extracted from health management information systems of 18 low- and lower-middle-income countries. Interrupted time series design is used to estimate percent change in the volumes of essential health services delivered during the pandemic compared to projected volumes based on pre-pandemic trends. The Lives Saved Tool mathematical model is used to estimate the impact of the service utilization disruptions on child and maternal mortality. In addition, the estimated monthly disruptions are also correlated to the COVID-19 burden, time since the start of the pandemic, and relative severity of mobility restrictions.Findings: We estimate that decreases in essential health service utilization between March 2020 and June 2021 led to 113,873 additional deaths in the 18 countries, representing 3.8% and 1.4% increases in child and maternal mortality, respectively. This corresponds to an average of 2.6 indirect deaths per COVID-19 death officially reported in the same period. This excess mortality results from the decline in utilization of the RMNCH services included in the analysis, but the utilization shortfalls vary substantially between countries, health services, and over time. The largest disruptions, resulting in 27.5% of the excess death, occurred during the second quarter of 2020, regardless of whether countries experienced the highest rate of COVID-19-related deaths during the same months. There is a significant relationship between the magnitude of service disruptions and the stringency of mobility restrictions. Interpretation: Large declines in health care utilization during the COVID-19 pandemic amplify the pandemic's harmful impacts on health outcomes. As efforts and resource allocation towards prevention and treatment of COVID-19 continue, essential health services must be maintained, particularly in low and middle-income countries.Funding: The Global Financing Facility for Women, Children, and Adolescents.Declaration of Interests: We declare no competing interests.

Research paper thumbnail of Annual Primary Care 2030 Convening: Creating an Enabling Ecosystem for Person-Centered Primary Healthcare Models to Achieve Universal Health Coverage in Low- and Middle-Income Countries

Annals of Global Health, 2020

reaffirm the highest level of political commitment by United Nations Member States to achieve acc... more reaffirm the highest level of political commitment by United Nations Member States to achieve access to health services and primary healthcare for all. Both documents emphasize the importance of person-centered care in both healthcare services and systems design. However, there is limited consensus on how to build a strong primary healthcare system to achieve these goals. Methods: We convened a diverse group of global stakeholders for a high-level dialogue on how to create a person-centered primary healthcare system, using the country examples of the Republic of Kenya and the Socialist Republic of Vietnam. We focused our discussion on four themes to enable the creation of personcentered primary healthcare systems in Kenya and Vietnam: (1) strengthened community, person and patient engagement in subnational and national decision making; (2) improved service delivery; (3) impactful use of innovation and technology; and (4) meaningful and timely use of measurement and data. Findings: Here, we present a summary of our convening's proceedings, with specific insights on how to enable a person-centered primary healthcare system within each of these four domains. Conclusions: Following the 2019 United Nations General Assembly High-Level Meeting on Universal Health Coverage and the 2018 Declaration of Astana, there is high-level commitment and global consensus that a person-centered approach is necessary to achieve high-quality primary healthcare and universal health coverage. We offer our recommendations to the global community to catalyze further discourse and inform policy-making and program development on the path to Universal Health Coverage by 2030.

Research paper thumbnail of COVID-19 Pandemic and Disruptions in Essential Health Services in Kenya

SSRN Electronic Journal, 2021

Background: Public health emergencies can disrupt provision and access of essential healthcare se... more Background: Public health emergencies can disrupt provision and access of essential healthcare services, exacerbating the health crisis. We assessed the effect of COVID-19 pandemic on essential healthcare services in Kenya, and how those varied with the burden of COVID-19 in different regions of the country. Methods: Using data routinely collected from health facilities across the country, we conducted interrupted time series analysis to examine the impact of COVID-19 on key indicators of essential healthcare. We fitted the models using the data from the pre-pandemic period, predicted the trends for the next 13 months for each indicator, and compared the predicted values with the observed cases during the pandemic period. We used Poisson models to estimate the monthly incident rate ratios for each indicator to compare the effect in regions with high and low COVID-19 burden. Findings: Outpatients visits declined by 21% during the pandemic, with children <5years and regions with higher COVID-19 cases more severely affected. Vaccinations against childhood illnesses, attendance to welfare clinics, screening for cervical cancer declined with largest declines observed during COVID-19 movement restrictions. Cases of sexual violence and diabetes increased, while those of pneumonia and diarrhoea decreased. Antenatal clinic visits, number of skilled deliveries, children receiving Vitamin A supplements remained unchanged. Interpretation: The COVID-19 pandemic in Kenya disrupted essential health services with utilization of outpatient visits, child immunization, screening and diagnostic services adversely affected. There is need for attention on these vulnerable essential services to prevent exacerbation of associated disease burdens during health crises. Funding Information: Centre for Epidemiological and Modelling Analysis, University of Nairobi receives support from Bill and Melinda Gates Foundation. Declaration of Interests: None to declare.

Research paper thumbnail of Predictors of adherance to HAART in Mbagathi district hospital

Background Adherence to highly active antiretroviral therapy (HAART) medications is critically im... more Background Adherence to highly active antiretroviral therapy (HAART) medications is critically important for the success of therapy in patients treated for Human Immunodeficiency virus Acquired Immunodeficiency Syndrome (HIV/AIDS). Successful long-term treatment of HIV/AIDS requires at least 95% adherence to HAART, which, based on a twice a day regimen, translates into missing no more than two doses per month. This high level of adherence is necessary to prevent emergence of drug-resistant HIV variants that lead to regimen failure, and limit options for future therapy. Several factors have been described in various settings as being associated with adherence. These are Psycho-Socio Support, Time on ART, Financial support, Psychosocial and Antiretroviral side effects. Patient factors have been found to be the most important predictors of adherence in most studies. The impact of unpunctuality for clinic appointments is closely associated with treatment outcomes for HAART. Virologic fa...

Research paper thumbnail of Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017

The Lancet, 2018

Background Efforts to establish the 2015 baseline and monitor early implementation of the UN Sust... more Background Efforts to establish the 2015 baseline and monitor early implementation of the UN Sustainable Development Goals (SDGs) highlight both great potential for and threats to improving health by 2030. To fully deliver on the SDG aim of "leaving no one behind", it is increasingly important to examine the health-related SDGs beyond national-level estimates. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017), we measured progress on 41 of 52 health-related SDG indicators and estimated the health-related SDG index for 195 countries and territories for the period 1990-2017, projected indicators to 2030, and analysed global attainment. Methods We measured progress on 41 health-related SDG indicators from 1990 to 2017, an increase of four indicators since GBD 2016 (new indicators were health worker density, sexual violence by non-intimate partners, population census status, and prevalence of physical and sexual violence [reported separately]). We also improved the measurement of several previously reported indicators. We constructed national-level estimates and, for a subset of health-related SDGs, examined indicator-level differences by sex and Socio-demographic Index (SDI) quintile. We also did subnational assessments of performance for selected countries. To construct the healthrelated SDG index, we transformed the value for each indicator on a scale of 0-100, with 0 as the 2•5th percentile and 100 as the 97•5th percentile of 1000 draws calculated from 1990 to 2030, and took the geometric mean of the scaled indicators by target. To generate projections through 2030, we used a forecasting framework that drew estimates from the broader GBD study and used weighted averages of indicator-specific and country-specific annualised rates of change from 1990 to 2017 to inform future estimates. We assessed attainment of indicators with defined targets in two ways: first, using mean values projected for 2030, and then using the probability of attainment in 2030 calculated from 1000 draws. We also did a global attainment analysis of the feasibility of attaining SDG targets on the basis of past trends. Using 2015 global averages of indicators with defined SDG targets, we calculated the global annualised rates of change required from 2015 to 2030 to meet these targets, and then identified in what percentiles the required global annualised rates of change fell in the distribution of country-level rates of change from 1990 to 2015. We took the mean of these global percentile values across indicators and applied the past rate of change at this mean global percentile to all health-related SDG indicators, irrespective of target definition, to estimate the equivalent 2030 global average value and percentage change from 2015 to 2030 for each indicator. Findings The global median health-related SDG index in 2017 was 59•4 (IQR 35•4-67•3), ranging from a low of 11•6 (95% uncertainty interval 9•6-14•0) to a high of 84•9 (83•1-86•7). SDG index values in countries assessed at the subnational level varied substantially, particularly in China and India, although scores in Japan and the UK were more homogeneous. Indicators also varied by SDI quintile and sex, with males having worse outcomes than females for non-communicable disease (NCD) mortality, alcohol use, and smoking, among others. Most countries were projected to have a higher health-related SDG index in 2030 than in 2017, while country-level probabilities of attainment by 2030 varied widely by indicator. Under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria indicators had the most countries with at least 95% probability of target attainment. Other indicators, including NCD mortality and suicide mortality, had no countries projected to meet corresponding SDG targets on the basis of projected mean values for 2030 but showed some probability of attainment by 2030. For some indicators, including child malnutrition, several infectious diseases, and most violence measures, the annualised rates of change required to meet SDG targets far exceeded the pace of progress achieved by any country in the recent past. We found that applying the mean global annualised rate of change to indicators without defined targets would equate to about 19% and 22% reductions in global smoking and alcohol consumption, respectively; a 47% decline in adolescent birth rates; and a more than 85% increase in health worker density per 1000 population by 2030.

Research paper thumbnail of Health service utilisation during the COVID-19 pandemic in sub-Saharan Africa in 2020: a multicountry empirical assessment with a focus on maternal, newborn and child health services

BMJ Global Health

IntroductionThere are concerns about the impact of the COVID-19 pandemic on the continuation of e... more IntroductionThere are concerns about the impact of the COVID-19 pandemic on the continuation of essential health services in sub-Saharan Africa. Through the Countdown to 2030 for Women’s, Children’s and Adolescents’ Health country collaborations, analysts from country and global public health institutions and ministries of health assessed the trends in selected services for maternal, newborn and child health, general service utilisation.MethodsMonthly routine health facility data by district for the period 2017–2020 were compiled by 12 country teams and adjusted after extensive quality assessments. Mixed effects linear regressions were used to estimate the size of any change in service utilisation for each month from March to December 2020 and for the whole COVID-19 period in 2020.ResultsThe completeness of reporting of health facilities was high in 2020 (median of 12 countries, 96% national and 91% of districts ≥90%), higher than in the preceding years and extreme outliers were few...

Research paper thumbnail of Health disparities across the counties of Kenya and implications for policy makers, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

The Lancet Global Health, 2019

Kenya has made progress in tackling various health challenges, particularly those linked to prior... more Kenya has made progress in tackling various health challenges, particularly those linked to priority communicable diseases. 7,8 Declines in diarrhoea, lower respiratory infections, and vaccine-preventable diseases have occurred alongside decreasing maternal and neonatal mortality, although mortality rates remain comparatively high and unequal across counties. 7,9,10 The Kenya Expanded Programme on Immunization endorses childhood vaccination for tuberculosis, polio, diphtheria, whooping cough, tetanus, measles, hepatitis B, Haemophilus influenzae type b, pneumococcus, and rotavirus. 11 Kenya has among the highest rates of HIV/AIDS and tuberculosis in the world, although mortality rates have declined since the early 2000s, particularly for HIV/AIDS. 12,13 Malaria mortality in children declined substantially between 2003 and 2007, 14,15 although reports indicate increasing incidence