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      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

      , PhD a , b , , MSc c , , MSc c , , DPhil c , , MIHMEP e , , MS g , , PhD h , , MS g , , MPH f , i , , PhD j , k , , MSc l , o , , PhD p , , Prof, PhD r , , MSc t , , PhD u , v , , PhD c , , MD w , , BA c , , BS x , , BS c , , PhD y , , Prof, MD m , n , , Dr PHD z , , PhD c , , MD aa , , PhD q , , Prof, MD s , , Prof, FMedSci c , d , , Prof, DPhil c , d , , Prof, MD c , d , *

      The Lancet. Global Health

      Elsevier Ltd

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          The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provided comprehensive estimates of health loss globally. Decision makers in Kenya can use GBD subnational data to target health interventions and address county-level variation in the burden of disease.


          We used GBD 2016 estimates of life expectancy at birth, healthy life expectancy, all-cause and cause-specific mortality, years of life lost, years lived with disability, disability-adjusted life-years, and risk factors to analyse health by age and sex at the national and county levels in Kenya from 1990 to 2016.


          The national all-cause mortality rate decreased from 850·3 (95% uncertainty interval [UI] 829·8–871·1) deaths per 100 000 in 1990 to 579·0 (562·1–596·0) deaths per 100 000 in 2016. Under-5 mortality declined from 95·4 (95% UI 90·1–101·3) deaths per 1000 livebirths in 1990 to 43·4 (36·9–51·2) deaths per 1000 livebirths in 2016, and maternal mortality fell from 315·7 (242·9–399·4) deaths per 100 000 in 1990 to 257·6 (195·1–335·3) deaths per 100 000 in 2016, with steeper declines after 2006 and heterogeneously across counties. Life expectancy at birth increased by 5·4 (95% UI 3·7–7·2) years, with higher gains in females than males in all but ten counties. Unsafe water, sanitation, and handwashing, unsafe sex, and malnutrition were the leading national risk factors in 2016.


          Health outcomes have improved in Kenya since 2006. The burden of communicable diseases decreased but continues to predominate the total disease burden in 2016, whereas the non-communicable disease burden increased. Health gains varied strikingly across counties, indicating targeted approaches for health policy are necessary.


          Bill & Melinda Gates Foundation.

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          Most cited references 41

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          GBD 2010: design, definitions, and metrics.

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            Changes in the burden of malaria in sub-Saharan Africa.

            The burden of malaria in countries in sub-Saharan Africa has declined with scaling up of prevention, diagnosis, and treatment. To assess the contribution of specific malaria interventions and other general factors in bringing about these changes, we reviewed studies that have reported recent changes in the incidence or prevalence of malaria in sub-Saharan Africa. Malaria control in southern Africa (South Africa, Mozambique, and Swaziland) began in the 1980s and has shown substantial, lasting declines linked to scale-up of specific interventions. In The Horn of Africa, Ethiopia and Eritrea have also experienced substantial decreases in the burden of malaria linked to the introduction of malaria control measures. Substantial increases in funding for malaria control and the procurement and distribution of effective means for prevention and treatment are associated with falls in malaria burden. In central Africa, little progress has been documented, possibly because of publication bias. In some countries a decline in malaria incidence began several years before scale-up of malaria control. In other countries, the change from a failing drug (chloroquine) to a more effective drug (sulphadoxine plus pyrimethamine or an artemisinin combination) led to immediate improvements; in others malaria reduction seemed to be associated with the scale-up of insecticide-treated bednets and indoor residual spraying. 2010 Elsevier Ltd. All rights reserved.
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              Effect of a fall in malaria transmission on morbidity and mortality in Kilifi, Kenya

              Summary Background As efforts to control malaria are expanded across the world, understanding the role of transmission intensity in determining the burden of clinical malaria is crucial to the prediction and measurement of the effectiveness of interventions to reduce transmission. Furthermore, studies comparing several endemic sites led to speculation that as transmission decreases morbidity and mortality caused by severe malaria might increase. We aimed to assess the epidemiological characteristics of malaria in Kilifi, Kenya, during a period of decreasing transmission intensity. Methods We analyse 18 years (1990–2007) of surveillance data from a paediatric ward in a malaria-endemic region of Kenya. The hospital has a catchment area of 250 000 people. Clinical data and blood-film results for more than 61 000 admissions are reported. Findings Hospital admissions for malaria decreased from 18·43 per 1000 children in 2003 to 3·42 in 2007. Over 18 years of surveillance, the incidence of cerebral malaria initially increased; however, malaria mortality decreased overall because of a decrease in incidence of severe malarial anaemia since 1997 (4·75 to 0·37 per 1000 children) and improved survival among children admitted with non-severe malaria. Parasite prevalence, the mean age of children admitted with malaria, and the proportion of children with cerebral malaria began to change 10 years before hospitalisation for malaria started to fall. Interpretation Sustained reduction in exposure to infection leads to changes in mean age and presentation of disease similar to those described in multisite studies. Changes in transmission might not lead to immediate reductions in incidence of clinical disease. However, longitudinal data do not indicate that reductions in transmission intensity lead to transient increases in morbidity and mortality. Funding Wellcome Trust, Kenya Medical Research Institute.

                Author and article information

                Lancet Glob Health
                Lancet Glob Health
                The Lancet. Global Health
                Elsevier Ltd
                25 October 2018
                January 2019
                25 October 2018
                : 7
                : 1
                : e81-e95
                [a ]Sloan Management, Massachusetts Institute of Technology, Cambridge, MA, USA
                [b ]Center for Pharmaceutical Policy and Regulation, Utrecht University, Utrecht, Netherlands
                [c ]Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
                [d ]Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
                [e ]Strategic Information and Learning, University of Research Company, Gaborone, Botswana
                [f ]Policy, Planning, and Healthcare Financing Department, Nairobi, Kenya
                [g ]Ministry of Health, Nairobi, Kenya
                [h ]International Center for Humanitarian Affairs, Nairobi, Kenya
                [i ]Institute of Tropical Medicine, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
                [j ]Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
                [k ]Epidemiology and Demography Department, Kilifi, Kenya
                [l ]Malaria Branch, Kilifi, Kenya
                [m ]Kenya Medical Research Institute (KEMRI)-Wellcome Trust Collaborative Programme, Kilifi, Kenya
                [n ]Department of Psychiatry, University of Oxford, Oxford, UK
                [o ]Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
                [p ]Population Dynamics and Reproductive Health Unit, Nairobi, Kenya
                [q ]African Population Health Research Centre, Nairobi, Kenya
                [r ]ODeL Campus, University of Nairobi, Nairobi, Kenya
                [s ]School of Medicine, University of Nairobi, Nairobi, Kenya
                [t ]Synotech Consultants, Nairobi, Kenya
                [u ]Faculty of Health, University of Canberra, Canberra, ACT, Australia
                [v ]Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Vic, Australia
                [w ]East Africa Center, Humanitarian Leadership Academy, Nairobi, Kenya
                [x ]Department of Health Systems and Research Ethics, KEMRI-Wellcome Research Programme, Nairobi, Kenya
                [y ]Department of Environmental Science, Egerton University, Egerton, Kenya
                [z ]Department of Biological Sciences, University of Embu, Embu, Kenya
                [aa ]Eastern Africa Regional Collaborating Centre, African Centre for Disease Control and Prevention, Nairobi, Kenya
                Author notes
                [* ]Correspondence to: Prof Mohsen Naghavi, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA 98121, USA nagham@
                © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

                This is an open access article under the CC BY license (



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