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This paper measures the effects of disruptions to healthcare quality at birth on early child health outcomes in Kenya. To identify impacts, we exploit variation in the timing and location of health-worker strikes at individual hospitals across the country between 1999 and 2014. Using data from Demographic Health Surveys, we find that children born during strikes are more likely to suffer a neonatal death. We find similar results using separate data collected in two informal settlements in Nairobi located near hospitals with frequent strikes. These results show that interruptions to healthcare quality can have large immediate health impacts, and suggests that status quo hospital care provides positive benefits. We also find suggestive evidence of reductions in later health investments, measured by vaccine take-up, among those who survive. This study provides the first rigorous evidence on the consequences of health-worker strikes, a frequent but understudied phenomenon in Sub-Saharan Africa., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: During the millennium development goals period, reduction in under-five mortality (U5M) and increases in child health intervention coverage were characterised by sub-national disparities and inequities across Kenya. The contribution of changing risk factors and intervention coverage on the sub-national changes in U5M remains poorly defined., Methods: Sub-national county-level data on U5M and 43 factors known to be associated with U5M spanning 1993 and 2014 were assembled. Using a Bayesian ecological mixed-effects regression model, the relationships between U5M and significant intervention and infection risk ecological factors were quantified across 47 sub-national counties. The coefficients generated were used within a counterfactual framework to estimate U5M and under-five deaths averted (U5-DA) for every county and year (1993-2014) associated with changes in the coverage of interventions and disease infection prevalence relative to 1993., Results: Nationally, the stagnation and increase in U5M in the 1990s were associated with rising human immunodeficiency virus (HIV) prevalence and reduced maternal autonomy while improvements after 2006 were associated with a decline in the prevalence of HIV and malaria, increase in access to better sanitation, fever treatment-seeking rates and maternal autonomy. Reduced stunting and increased coverage of early breastfeeding and institutional deliveries were associated with a smaller number of U5-DA compared to other factors while a reduction in high parity and fully immunised children were associated with under-five lives lost. Most of the U5-DA occurred after 2006 and varied spatially across counties. The highest number of U5-DA was recorded in western and coastal Kenya while northern Kenya recorded a lower number of U5-DA than western. Central Kenya had the lowest U5-DA. The deaths averted across the different regions were associated with a unique set of factors., Conclusion: Contributions of interventions and risk factors to changing U5M vary sub-nationally. This has important implications for targeting future interventions within decentralised health systems such as those operated in Kenya. Targeting specific factors where U5M has been high and intervention coverage poor would lead to the highest likelihood of sub-national attainment of sustainable development goal (SDG) 3.2 on U5M in Kenya.

Background: Child mortality rates during hospitalisation for acute illness and after discharge are unacceptably high in many under-resourced settings. Childhood vulnerability to recurrent illness, and death, is linked to their families' situations and ability to make choices and act (their agency). We examined vulnerability and agency across treatment-seeking journeys for acutely ill children and considered the implications for policy and practice., Method: A qualitative sub-study was embedded within the prospective CHAIN Network cohort study, which is investigating mechanisms of inpatient and post-hospital discharge mortality among acutely ill young children across a spectrum of nutritional status. Primary data were collected from household members of 20 purposively selected cohort children over 18 months through formal interviews (total n = 74), complemented by informal discussions and observations. Data were analysed using narrative and thematic approaches., Results: Treatment-seeking pathways were often long and complex, particularly for children diagnosed as severely malnourished. Family members' stories reveal that children's carers, usually mothers, navigate diverse challenges related to intersecting vulnerabilities at individual, household and facility levels. Specific challenges include the costs of treatment-seeking, confusing and conflicting messaging on appropriate care and nutrition, and poor continuity of care. Strong power inequities were observed between family members and health staff, with many mothers feeling blamed for their child's condition. Caregivers' agency, as demonstrated in decision-making and actions, often drew on the social support of others but was significantly constrained by their situation and broader structural drivers., Conclusion: To support children's care and recovery, health systems must be more responsive to the needs of families facing multiple and interacting vulnerabilities. Reducing incurred treatment costs, improving interpersonal quality of care, and strengthening continuity of care across facilities is essential. Promising interventions need to be co-designed with community representatives and health providers and carefully tested for unintended negative consequences and potential for sustainable scale-up.

Background: Minimally invasive tissue sampling (MITS) is a simplified postmortem examination technique that has shown to be an adequate approach for cause of death investigation in low-resource settings. It requires relatively low level of infrastructures and can be performed by health professionals with no background in pathology. A training program has been developed for the Child Health and Mortality Prevention Surveillance (CHAMPS) network to guarantee standardization of specimen collection techniques, procedures, and laboratory methods., Methods: The training program has included assessment of the site capacities and training on a standardized protocol of MITS sampling and histological processing. The project has also introduced a program of training for trainers for the personnel from Mozambique. To guarantee the adequacy of the procedure in each site, a trainer accompanied the local teams when the activities started. Training outcomes were assessed by evaluating the quality of the samples obtained and the quality of the slides produced locally., Results: Between June 2016 and October 2018, the laboratories of 7 sites (Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) have been evaluated and upgraded. Training has been delivered to 63 staff members from all sites. More than 600 MITS procedures have been performed. The quantity of tissue obtained in the MITS by the local teams was sufficient or abundant in 73%, and 87% of the slides were considered as technically acceptable or excellent., Conclusions: Satisfactory standardization of MITS and histology procedures has been achieved across all CHAMPS sites through organized capacity-building plans., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America.)

Reducing child mortality is a key global health challenge. We examined reasons for greater or lesser success in meeting under-five mortality rate reductions, i.e. Millennium Development Goal #4, between 1990 and 2015 in Sub-Saharan Africa where child mortality remains high. We first examined factors associated with child mortality from all World Health Organization African Region nations during the Millennium Development Goal period. This analysis was followed by case studies of the facilitators and barriers to Millennium Development Goal #4 in four countries – Kenya, Liberia, Zambia, and Zimbabwe. Quantitative indicators, policy documents, and qualitative interviews and focus groups were collected from each country to examine factors within and across countries related to child mortality. We found familiar themes that highlighted the need for both specific services (e.g. primary care access, emergency obstetric and neonatal care) and general management (e.g. strong health governance and leadership, increasing community health workers, quality of care). We also identified methodological opportunities and challenges to assessing progress in child health, which can provide insights to similar efforts during the Sustainable Development Goal period. Specifically, it is important for countries to adapt general international goals and measurements to their national context, considering baseline mortality rates and health information systems, to develop country-specific goals. It will also be critical to develop more rigorous measurement tools and indicators to accurately characterize maternal, neonatal, and child health systems, particularly in the area of governance and leadership. Valuable lessons can be learned from Millennium Development Goal successes and failures, as well as how they are evaluated. As countries seek to lower child mortality further during the Sustainable Development Goal period, it will be necessary to prioritize and support countries in quantitative and qualitative data collection to assess and contextualize progress, identifying areas needing improvement. [ABSTRACT FROM AUTHOR]

The Child Health and Mortality Prevention Surveillance (CHAMPS) program is a 7-country network (as of December 2018) established by the Bill & Melinda Gates Foundation to identify the causes of death in children in communities with high rates of under-5 mortality. The program carries out both mortality and pregnancy surveillance, and mortality surveillance employs minimally invasive tissue sampling (MITS) to gather small samples of body fluids and tissue from the bodies of children who have died. While this method will lead to greater knowledge of the specific causes of childhood mortality, the procedure is in tension with cultural and religious norms in many of the countries where CHAMPS works—Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa. Participatory Inquiry Into Community Knowledge of Child Health and Mortality Prevention (PICK-CHAMP) is a community entry activity designed to introduce CHAMPS to communities and gather initial perspectives on alignments and tensions between CHAMPS activities and community perceptions and priorities. Participants' responses revealed medium levels of overall alignment in all sites (with the exception of South Africa, where alignment was high) and medium levels of tension (with the exception of Ethiopia, where tension was high). Alignment was high and tension was low for pregnancy surveillance across all sites, whereas Ethiopia reflected low alignment and high tension for MITS. Participants across all sites indicated that support for MITS was possible only if the procedure did not interfere with burial practices and rituals. [ABSTRACT FROM AUTHOR]

Exposure to air pollution is associated with adverse health outcomes. However, the health burden related to ambient outdoor air pollution in sub-Saharan Africa remains unclear. This study examined the relationship between exposure to outdoor air pollution and child health in urban slums of Nairobi, Kenya. We conducted a semi-ecological study among children under 5 years of age from two slum areas and exposure measurements of particulate matter (PM2.5) at the village level were aligned to data from a retrospective cohort study design. We used logistic and Poisson regression models to ascertain the associations between PM2.5 exposure level and child morbidity and mortality. Compared to those in low-pollution areas (PM2.5 < 25 µg/m³), children in high-pollution areas (PM2.5 ≥ 25 µg/m³) were at significantly higher risk for morbidity in general (odds ratio (OR) = 1.25, 95% confidence interval (CI): 1.11-1.41) and, specifically, cough (OR = 1.38, 95% CI: 1.20-1.48). Exposure to high levels of pollution was associated with a high child mortality rate from all causes (IRR = 1.22, 95% CI: 1.08-1.39) and respiratory causes (IRR = 1.12, 95% CI: 0.88-1.42). The findings indicate that there are associated adverse health outcomes with air pollution in urban slums. Further research on air pollution health impact assessments in similar urban areas is required. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The U.S. is the main country in the world that delivers its food assistance primarily via transoceanic shipments of commodity-based in-kind food. This approach is costlier and less timely than cash-based assistance, which includes cash transfers, food vouchers, and local and regional procurement, where food is bought in or nearby the recipient country. The U.S.’s approach is exacerbated by a requirement that half of its transoceanic food shipments need to be sent on U.S.-flag vessels. We estimate the effect of these U.S. food assistance distribution policies on child mortality in northern Kenya by formulating and optimizing a supply chain model. In our model, monthly orders of transoceanic shipments and cash-based interventions are chosen to minimize child mortality subject to an annual budget constraint and to policy constraints on the allowable proportions of cash-based interventions and non-US-flag shipments. By varying the restrictiveness of these policy constraints, we assess the impact of possible changes in U.S. food aid policies on child mortality. The model includes an existing regression model that uses household survey data and geospatial data to forecast the mean mid-upper-arm circumference Z scores among children in a community, and allows food assistance to increase Z scores, and Z scores to influence mortality rates. We find that cash-based interventions are a much more powerful policy lever than the U.S.-flag vessel requirement: switching to cash-based interventions reduces child mortality from 4.4% to 3.7% (a 16.2% relative reduction) in our model, whereas eliminating the U.S.-flag vessel restriction without increasing the use of cash-based interventions generates a relative reduction in child mortality of only 1.1%. The great majority of the gains achieved by cash-based interventions are due to their reduced cost, not their reduced delivery lead times; i.e., the reduction of shipping expenses allows for more food to be delivered, which reduces child mortality. [ABSTRACT FROM AUTHOR]

Background The 'resource readiness' of health facilities to provide effective services is captured in the structure component of the classical Donabedian paradigm often used for assessment of the quality of care in the health sector. Periodic inventories are commonly used to confirm the presence (or absence) of equipment or drugs by physical observation or by asking those in charge to indicate whether an item is present or not. It is then assumed that this point observation is representative of the everyday status. However the availability of an item (consumables) may vary. Arguably therefore a more useful assessment for resources would be one that captures this fluctuation in time. Here we report an approach that may circumvent these difficulties.Methods We used self-administered questionnaires (SAQ) to seek health worker views of availability of key resources supporting paediatric care linked to a cluster randomized trial of a multifaceted intervention aimed at improving this care conducted in eight rural Kenyan district hospitals. Four hospitals received a full intervention and four a partial intervention. Data were collected pre-intervention and after 6 and 18 months from health workers in three clinical areas asked to score item availability using an 11-point scale. Mean scores for items common to all 3 areas and mean scores for items allocated to domains identified using exploratory factor analysis (EFA) were used to describe availability and explore changes over time. Results SAQ were collected from 1,156 health workers. EFA identified 11 item domains across the three departments. Mean availability scores for these domains were often <5/10 at baseline reflecting lack of basic resources such as oxygen, nutrition and second line drugs. An improvement in mean scores occurred in 8 out of 11 domains in both control and intervention groups. A calculation of difference in difference of means for intervention vs. control suggested an intervention effect resulting in greater changes in 5 out of 11 domains. Conclusion Using SAQ data to assess resource availability experienced by health workers provides an alternative to direct observations that provide point prevalence estimates. Further the approach was able to demonstrate poor access to resources, change over time and variability across place. [ABSTRACT FROM AUTHOR]

Background If effective interventions are to be used to address child mortality and malnutrition, then it is important that we understand the different pathways operating within the framework of child health. More attention needs to be given to understanding the contribution of social influences such as intimate partner violence (IPV). Aim To investigate the relationship between maternal exposure to IPV and child mortality and malnutrition using data from five developing countries. Methods Population data from Egypt, Honduras, Kenya, Malawi and Rwanda were analysed. Logistic regression analysis was used to generate odds ratios of the associations between several categories of maternal exposure to IPV since the age of 15 and three child outcomes: under-2-year-old (U2) mortality and moderate and severe stunting (<–2 Z-score height-for-age and <–3 Z-score height-for-age) in 6–59-month-old children. Analyses were adjusted for potential confounders, and the role of mediating factors was explored. Results The prevalence of physical and/or sexual IPV since the age of 15 years ranged from 15.5% (Honduras) to 46.2% (Kenya). For child stunting, prevalence ranged from 25.4% (Egypt) to 58.0% (Malawi) and for U2 mortality from 3.6% (Honduras) to 15.2% (Rwanda). In Kenya, maternal exposure to IPV was associated with higher U2 mortality (adjusted odds ratio (OR)=1.42, 95% CI 1.18 to 1.71) and child stunting (adjusted OR=1.36, 95% CI 1.16 to 1.61). In Malawi and Honduras, marginal associations were observed between IPV and severe stunting and U2 mortality, respectively, with strength of associations varying by type of violence. Conclusion The relationship between IPV and U2 mortality and stunting in Kenya, Honduras and Malawi suggests that, in these countries, IPV plays a role in child malnutrition and mortality. This contributes to a growing body of evidence that broader public health benefits may be incurred if efforts to address IPV are incorporated into a wider range of maternal and child health programmes; however, the authors highlight the need for more research that can establish temporality, use data collected on the basis of the study's objectives, and further explore the causal framework of this relationship using more advanced statistical analysis. [ABSTRACT FROM PUBLISHER]