Vaccination Utilization and Subnational Inequities during the COVID-19 Pandemic: An Interrupted Time-Series Analysis of Administrative Data across 12 Low- and Middle-Income Countries.

BACKGROUND: During and after the SARS-CoV-2 (COVID-19) pandemic, many countries experienced declines in immunization that have not fully recovered to pre-pandemic levels. This study uses routine health facility immunization data to estimate variability between and within countries in post-pandemic immunization service recovery for BCG, DPT1, and DPT3. METHODS: After adjusting for data reporting completeness and outliers, interrupted time series regression was used to estimate the expected immunization service volume for each subnational unit, using an interruption point of March 2020. We assessed and compared the percent deviation of observed immunizations from the expected service volume for March 2020 between and within countries. RESULTS: Six countries experienced significant service volume declines for at least one vaccine as of October 2022. The shortfall in BCG service volume was ~6% (95% CI -1.2%, -9.8%) in Guinea and ~19% (95% CI -16%, 22%) in Liberia. Significant cumulative shortfalls in DPT1 service volume are observed in Afghanistan (-4%, 95% CI -1%, -7%), Ghana (-3%, 95% CI -1%, -5%), Haiti (-7%, 95% CI -1%, -12%), and Kenya (-3%, 95% CI -1%, -4%). Afghanistan has the highest percentage of subnational units reporting a shortfall of 5% or higher in DPT1 service volume (85% in 2021 Q1 and 79% in 2020 Q4), followed by Bangladesh (2020 Q1, 83%), Haiti (80% in 2020 Q2), and Ghana (2022 Q2, 75%). All subnational units in Bangladesh experienced a 5% or higher shortfall in DPT3 service volume in the second quarter of 2020. In Haiti, 80% of the subnational units experienced a 5% or higher reduction in DPT3 service volume in the second quarter of 2020 and the third quarter of 2022. CONCLUSIONS: At least one region in every country has a significantly lower-than-expected post-pandemic cumulative volume for at least one of the three vaccines. Subnational monitoring of immunization service volumes using disaggregated routine health facility information data should be conducted routinely to target the limited vaccination resources to subnational units with the highest inequities.

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

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 action by the Government of Kenya and other agencies to mobilise resources (approximately USD 218 million). Earlier efforts were largely directed towards advanced critical care but since the human resource gap could not be reduced immediately, a lot of equipment remained unused. We also note that despite strong policies on what resources should be available, the reality on the ground was that there were often critical shortages. While emergency response mechanisms are not conducive to addressing long-term health system issues, the pandemic increased global recognition of the need to fund care for the critically ill. Limited resources may be best prioritised towards a public health approach with focus on provision of relatively basic, lower cost essential emergency and critical care (EECC) that can potentially save the most lives amongst critically ill patients.

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.

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 projected volumes based on prepandemic trends. The Lives Saved Tool mathematical model was used to project the impact of the service utilization disruptions on child and maternal mortality. In addition, the estimated monthly disruptions were also correlated to the monthly number of COVID-19 deaths officially reported, time since the start of the pandemic, and relative severity of mobility restrictions. Across the 18 countries, we estimate an average decline in OPD volume of 13.1% and average declines of 2.6% to 4.6% for maternal and child services. We projected that decreases in essential health service utilization between March 2020 and June 2021 were associated with 113,962 excess deaths (110,686 children under 5, and 3,276 mothers), representing 3.6% and 1.5% increases in child and maternal mortality, respectively. This excess mortality is associated with the decline in utilization of the essential health services included in the analysis, but the utilization shortfalls vary substantially between countries, health services, and over time. The largest disruptions, associated with 27.5% of the excess deaths, occurred during the second quarter of 2020, regardless of whether countries reported the highest rate of COVID-19-related mortality during the same months. There is a significant relationship between the magnitude of service disruptions and the stringency of mobility restrictions. The study is limited by the extent to which administrative data, which varies in quality across countries, can accurately capture the changes in service coverage in the population. CONCLUSIONS: Declines in healthcare utilization during the COVID-19 pandemic amplified the pandemic's harmful impacts on health outcomes and threaten to reverse gains in reducing maternal and child mortality. As efforts and resource allocation toward prevention and treatment of COVID-19 continue, essential health services must be maintained, particularly in low- and middle-income countries.

The COVID-19 pandemic and disruptions to essential health services in Kenya: a retrospective time-series analysis.

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.

Characterising Kenyan hospitals' suitability for medical officer internship training: a secondary data analysis of a cross-sectional study.

OBJECTIVE: To characterise the capacity of Kenya internship hospitals to understand whether they are suitable to provide internship training for medical doctors. DESIGN: A secondary data analysis of a cross-sectional health facility assessment (Kenya Harmonized Health Facility Assessment (KHFA) 2018). SETTING AND POPULATION: We analysed 61 out of all 74 Kenyan hospitals that provide internship training for medical doctors. OUTCOME MEASURES: 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 capacity index was calculated as the mean of 12 domain-specific scores for each facility. RESULTS: The 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 out of 61 hospitals have five or more specialists assigned, employed, seconded or part-time-as required by the national guideline. Quality and safety score was low across all hospitals with an average score of 40%. As for major specialties, all hospitals have good capacity for surgery and obstetrics-gynaecology, while mental health was poorest in comparison. Level 5 and 6 facilities (provincial and national hospitals) have higher capacity scores in all domains when compared with level 4 hospitals (equivalent to district hospitals). CONCLUSION: Major gaps exist in staffing, equipment and service availability of Kenya internship hospitals. Level 4 hospitals (equivalent to district hospitals) are more likely to have a lower capacity index, leading to low quality of care, and should be reviewed and improved to provide appropriate and well-resourced training for interns and to use appropriate resources to avoid improvising.

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.

INTRODUCTION: There 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. METHODS: Monthly 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. RESULTS: The 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. The country median reduction in utilisation of nine health services for the whole period March-December 2020 was 3.9% (range: -8.2 to 2.4). The greatest reductions were observed for inpatient admissions (median=-17.0%) and outpatient admissions (median=-7.1%), while antenatal, delivery care and immunisation services generally had smaller reductions (median from -2% to -6%). Eastern African countries had greater reductions than those in West Africa, and rural districts were slightly more affected than urban districts. The greatest drop in services was observed for March-June 2020 for general services, when the response was strongest as measured by a stringency index. CONCLUSION: The district health facility reports provide a solid basis for trend assessment after extensive data quality assessment and adjustment. Even the modest negative impact on service utilisation observed in most countries will require major efforts, supported by the international partners, to maintain progress towards the SDG health targets by 2030.

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.

Background: The 2019 United Nations General Assembly High-Level Meeting on Universal Health Coverage and the 2018 Declaration of Astana 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 person-centered 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.

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.

BACKGROUND: 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. METHODS: 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. FINDINGS: 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. INTERPRETATION: 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. FUNDING: Bill & Melinda Gates Foundation.