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      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

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          Abstract

          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.

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          Achieving child survival goals: potential contribution of community health workers.

          There is renewed interest in the potential contribution of community health workers to child survival. Community health workers can undertake various tasks, including case management of childhood illnesses (eg, pneumonia, malaria, and neonatal sepsis) and delivery of preventive interventions such as immunisation, promotion of healthy behaviour, and mobilisation of communities. Several trials show substantial reductions in child mortality, particularly through case management of ill children by these types of community interventions. However, community health workers are not a panacea for weak health systems and will need focussed tasks, adequate remuneration, training, supervision, and the active involvement of the communities in which they work. The introduction of large-scale programmes for community health workers requires evaluation to document the impact on child survival and cost effectiveness and to elucidate factors associated with success and sustainability.
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            Tanzania's countdown to 2015: an analysis of two decades of progress and gaps for reproductive, maternal, newborn, and child health, to inform priorities for post-2015.

            Tanzania is on track to meet Millennium Development Goal (MDG) 4 for child survival, but is making insufficient progress for newborn survival and maternal health (MDG 5) and family planning. To understand this mixed progress and to identify priorities for the post-2015 era, Tanzania was selected as a Countdown to 2015 case study.
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              How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys.

              Achievement of global health goals will require assessment of progress not only nationally but also for population subgroups. We aimed to assess how the magnitude of socioeconomic inequalities in health changes in relation to different rates of national progress in coverage of interventions for the health of mothers and children. We assessed coverage in low-income and middle-income countries for which two Demographic Health Surveys or Multiple Indicator Cluster Surveys were available. We calculated changes in overall coverage of skilled birth attendants, measles vaccination, and a composite coverage index, and examined coverage of a newly introduced intervention, use of insecticide-treated bednets by children. We stratified coverage data according to asset-based wealth quintiles, and calculated relative and absolute indices of inequality. We adjusted correlation analyses for time between surveys and baseline coverage levels. We included 35 countries with surveys done an average of 9·1 years apart. Pro-rich inequalities were very prevalent. We noted increased coverage of skilled birth attendants, measles vaccination, and the composite index in most countries from the first to the second survey, while inequalities were reduced. Rapid changes in overall coverage were associated with improved equity. These findings were not due to a capping effect associated with limited scope for improvement in rich households. For use of insecticide-treated bednets, coverage was high for the richest households, but countries making rapid progress did almost as well in reaching the poorest groups. National increases in coverage were primarily driven by how rapidly coverage increased in the poorest quintiles. Equity should be accounted for when planning the scaling up of interventions and assessing national progress. Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Brazil, Canada, Norway, Sweden, and UK. Copyright © 2012 Elsevier Ltd. All rights reserved.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                1 August 2017
                2017
                : 12
                : 8
                : e0181777
                Affiliations
                [1 ] University of Connecticut, Department of Anthropology, Storrs, Connecticut, United States of America
                [2 ] Jomo Kenyatta University of Agriculture and Technology, School of Public Health, Nairobi, Kenya
                [3 ] Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
                [4 ] Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
                [5 ] Kenya Ministry of Health, Nairobi, Kenya
                [6 ] World Health Organization/Kenya Country Office, Nairobi, Kenya
                [7 ] WHO Inter-country Support Team for East and Southern Africa, Harare, Zimbabwe
                [8 ] WHO Regional Office for Africa, Brazzaville, Congo
                [9 ] Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
                The Hospital for Sick Children, CANADA
                Author notes

                Competing Interests: SK is a paid employee of the Kenya Ministry of Health. KS, TD, and KM are paid employees of the World Health Organization. This does not alter our adherence to PLOS ONE policies on sharing data and materials. All other authors have no competing interests.

                • Conceptualization: MAB CAH KM SHV AMK.

                • Data curation: MAB KN CAH AMK.

                • Formal analysis: MAB CAH AMK.

                • Funding acquisition: KM SHV AMK.

                • Investigation: MAB KN CAH AMK.

                • Methodology: MAB KN CAH SK KS TD KM SHV AMK.

                • Project administration: KM AMK.

                • Resources: SK KS TD KM.

                • Supervision: MAB CAH TD KM SHV AMK.

                • Visualization: MAB CAH AMK.

                • Writing – original draft: MAB KN CAH SK KS AMK.

                • Writing – review & editing: MAB KN CAH SK KS TD KM SHV AMK.

                Article
                PONE-D-16-36941
                10.1371/journal.pone.0181777
                5538680
                28763454
                67fc88c6-341e-41ca-835c-5ffdc47190cd
                © 2017 Brault et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 14 September 2016
                : 6 July 2017
                Page count
                Figures: 2, Tables: 3, Pages: 20
                Funding
                Funded by: World Health Organization Regional Office for Africa
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100006108, National Center for Advancing Translational Sciences;
                Award ID: UL1 TR000445
                Funded by: funder-id http://dx.doi.org/10.13039/100000026, National Institute on Drug Abuse;
                Award ID: R25 DA035692
                Award Recipient :
                Funding for this project was provided by the World Health Organization Regional Office for Africa. Funding for this project was provided by the WHO. Support for data management came from the Vanderbilt Institute for Clinical and Translational Research (grant UL1 TR000445 from the National Center for Advancing Translational Sciences at the National Institutes of Health). At the time of the study, Dr. Kipp was a Scholar with the HIV/AIDS, Substance Abuse, and Trauma Training Program (HA-STTP), at the University of California, Los Angeles; supported through an award from the National Institute on Drug Abuse at the National Institutes of Health (R25 DA035692).
                Categories
                Research Article
                People and Places
                Geographical Locations
                Africa
                Kenya
                Medicine and Health Sciences
                Pediatrics
                Child Health
                Medicine and Health Sciences
                Public and Occupational Health
                Child Health
                People and Places
                Demography
                Death Rates
                Medicine and Health Sciences
                Health Care
                Health Care Policy
                Medicine and Health Sciences
                Health Care
                Health Care Policy
                Health Systems Strengthening
                Medicine and Health Sciences
                Health Care
                Health Care Facilities
                Medicine and Health Sciences
                Health Care
                Health Care Policy
                Child and Adolescent Health Policy
                Medicine and Health Sciences
                Health Care
                Health Education and Awareness
                Custom metadata
                Annual mortality estimates used in Figure 1 are publicly available, without restriction, from http://www.childmortality.org/index.php?r=site/graph#ID=KEN_Kenya. Indicator data used for Figure 2 are publicly available, without restriction, from the World Development Index, Africa Development Index, and Health Nutrition & Population Statistics databases of the World Bank Data Catalog ( http://data.worldbank.org/data-catalog/) or Kenya Demographic and Health Survey reports available at http://dhsprogram.com/Where-We-Work/Country-Main.cfm?ctry_id=20&c=Kenya&r=1. A detailed description of each indicator’s source can be found in the supplemental material from a previously published study (Kipp et al. BMJ Open. 2016. http://dx.doi.org/10.1136/bmjopen-2015-007675). Supplemental table S1 lists the national documents reviewed for the study. These were obtained with the permission and assistance of the Kenyan co-authors. As such, they cannot be made available as they belong to the Ministry of Health or other agencies and some are still in draft form. Investigators wishing to utilize policy documents for research purposes are encouraged to work directly with Kenyan collaborators. Requests for national documents should be directed to Dr. Stewart Kabaka ( skabaka72@ 123456gmail.com ), at the Kenya Ministry of Health or Dr. Kibet Sergon ( sergonk@ 123456who.int ), at the WHO Kenya Country Office. Under the Agreement for Performance of Work with the World Health Organization (sponsor) that was used for this study, all rights to the data collected from key informants and community women belong to the WHO. The WHO will entertain any reasonable proposal for use of the data. Researchers who are qualified to manage and analyze qualitative data may request these data from Dr. Phanuel Habimana, Team Leader, Child and Adolescent Health and Nutrition, WHO Regional Office for Africa, Brazzaville, Congo; email: habimanap@ 123456who.int .

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