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Background Access to primary healthcare is crucial for the delivery of Kenya’s universal health coverage policy. However, disparities in healthcare have proved to be the biggest challenge for implementing primary care in poor-urban resource settings. In this study, we assessed the level of access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya. Methods The data were drawn from the Lown scholars’ study of 300 randomly selected households in Viwandani slums (Nairobi, Kenya), between June and July 2018. Access to primary care was measured using Penchansky and Thomas’ model. Access index was constructed using principal component analysis and recorded into tertiles with categories labeled as poor, moderate, and highest. Generalized ordinal logistic regression analysis was used to determine the factors associated with access to primary care. The adjusted odds ratios (AOR) and 95% confidence intervals were used to interpret the strength of associations. Results The odds of being in the highest access tertile versus the combined categories of lowest and moderate access tertile were three times higher for males than female-headed households (AOR 3.05 [95% CI 1.47–6.37]; p  < .05). Households with an average quarterly out-of-pocket healthcare expenditure of ≥USD 30 had significantly lower odds of being in the highest versus combined categories of lowest and moderate access tertile compared to those spending ≤ USD 5 (AOR 0.36 [95% CI 0.18–0.74]; p  < .05). Households that sought primary care from private facilities had significantly higher odds of being in the highest versus combined categories of lowest and moderate access tertiles compared to those who sought care from public facilities (AOR 6.64 [95% CI 3.67–12.01]; p  < .001). Conclusion In Nairobi slums in Kenya, living in a female-headed household, seeking care from a public facility, and paying out-of-pocket for healthcare are significantly associated with low access to primary care. Therefore, the design of the UHC program in this setting should prioritize quality improvement in public health facilities and focus on policies that encourage economic empowerment of female-headed households to improve access to primary healthcare.

Community-Based Health Insurance (CBHI) is an emerging concept for providing financial protection against the cost of illness and improving access to quality health services for low-income rural households who are excluded from formal insurance. CBHI is currently being provided in some rural areas in developing countries and there is ongoing research about its impact on the well-being of the poor in these areas. However, the success of CBHI revolves around the existence of social capital in the community. This has led researchers to explore the impact of CBHI on the well-being of the poor in rural areas, especially as it relates to social capital. The overall objective of this paper is to review recent developments that address the link between CBHI and social capital. Policy implications are also discussed.

Background Immunization is one of the most cost-effective health intervention to halt the spread of childhood diseases, and improve child health. Yet, there is a substantial disparity in childhood immunization coverage. The overall objective of the study is to investigate the trends of within-country inequalities in childhood immunization coverage among children aged 12–23 months in Kenya, Ghana, and Côte d’Ivoire. The three countries included in this study are countries that are on the verge of entering the accelerated phase of the Gavi, the Vaccine Alliance’s co-sharing of costs of vaccine and eventually assuming full costs of vaccines. Côte d’Ivoire is in the Gavi preparatory transition phase, entering the accelerated transition phase in 2020, with an expected transition to full self-financing in 2025. Ghana is expected to enter the accelerated transition phase in 2021 and to full self-financing in 2026 while Kenya will enter in 2022 and fully self-finance in 2027. We examine the pattern of inequality in childhood immunization coverage over time through an equity lens by mainly exploring the direction of inequality in coverage. Methods We use data from the Demographic Health Surveys and Multiple Indicator Cluster Surveys. The rate difference, rate ratio, and relative concentration index are used as measures of inequality. Results Results of the study suggest that in most years inequality in immunization coverage in the three countries persist over time, and it favors the most-advantaged households. However, there is a sharp decrease pattern in inequalities in childhood immunization coverage in Ghana over time. Conclusion Policymakers could be more strategic in addressing pro-rich inequality in immunization coverage by designing health interventions through an equity lens. Using inequality data and putting disadvantaged households at the center of health intervention designs could increase the efficiency of the primary health care system and reduce the incidence of mortality and morbidity as a result of vaccine-preventable disease.

Background Knowledge of health care utilization is important in low-and middle-income countries where inequalities in the burden of diseases and access to primary health care exist. Limited evidence exists on health seeking and utilization in the informal settlements in Kenya. This study assessed the patterns and predictors of private and public health care utilization in an urban informal settlement in Kenya. Methods This study used data from the Lown scholars study conducted between June and July 2018. A total of 300 households were randomly selected and data collected from 364 household members who reported having sought care for an illness in the 12 months preceding the study. Data were collected on health-seeking behaviour and explanatory variables (predisposing, enabling, and need factors). Health care utilization patterns were described using proportions. Predictors of private or public health care use were identified using multinomial logistic regression with the reference group being other providers. Results Majority of the participants used private (47%) and public facilities (33%) with 20% using other providers including local pharmacies/drug shops and traditional healers. In the model comparing public facilities vs other facilities, members who were satisfied with the quality of health care (vs not satisfied) were less likely to use public facilities (adjusted relative risk ratio (aRRR) 0.29; CI 0.11–0.76) while members who reported an acute infection (vs no acute infection) were more likely to use public facilities (aRRR 2.31; 95% CI 1.13–4.99) compared to other facilities. In the second model comparing private facilities to other facilities, having health insurance coverage (aRRR 2.95; 95% CI 1.53–5.69), satisfaction with cost of care (aRRR 2.08; CI 1.00–4.36), and having an acute infection (aRRR 2.97; 95% CI 1.50–5.86) were significantly associated with private facility use compared to other facilities. Conclusions The majority of urban informal settlement dwellers seek care from private health facilities. As Kenya commits to achieving universal health coverage, interventions that improve health care access in informal and low-resource settlements are needed and should be modelled around enabling and need factors, particularly health care financing and quality of health care.

This paper aims at assessing and exploring socioeconomic inequalities in tobacco use in Kenya. Using the theory of fundamental causes, and concentration index, we investigate the determinants of tobacco use, and whether it disproportionately affects the poor. All data used in this study emanated from the 2014 Global Adult Tobacco Survey implemented in Kenya on a nationally representative sample of men and women aged 15 years and older. Our results suggest a link between tobacco use and socioeconomic inequality. Overall, poorer households are more affected by tobacco use than richer households. This socioeconomic inequality is more evident among men and households living in urban areas. The decomposition of the concentration index indicates that the overall socioeconomic inequality for current tobacco smokers is explained by 69.11% of household wealth. To reduce the prevalence rate of smoking in Kenya, policymakers could design and implement tobacco control programs through the equity lens. Community health workers could be used to promote non-smoking behaviors among the poor.

Background Universal Health Coverage ensures access to quality health services for all, with no financial hardship when accessing the needed services. Nevertheless, access to quality health services is marred by substantial resource shortages creating service delivery gaps in low-and middle-income countries, including Kenya. The Innovative Partnership for Universal Sustainable Healthcare ( i -PUSH) program, developed by AMREF Health Africa and PharmAccess Foundation (PAF), aims to empower low-income women of reproductive age and their families through innovative digital tools. This study aims to evaluate the impact of i -PUSH on maternal and child health care utilization, women’s health including their knowledge, behavior, and uptake of respective services, as well as women’s empowerment and financial protection. It also aims to evaluate the impact of the LEAP training tool on empowering and enhancing community health volunteers’ health literacy and to evaluate the impact of the M-TIBA health wallet on savings for health and health insurance uptake. Methods This is a study protocol for a cluster randomized controlled trial (RCT) study that uses a four-pronged approach—including year-long weekly financial and health diaries interviews, baseline and endline surveys, a qualitative study, and behavioral lab-in-the-field experiments—in Kakemega County, Kenya. In total, 240 households from 24 villages in Kakamega will be followed to capture their health, health knowledge, health-seeking behavior, health expenditures, and enrolment in health insurance over time. Half of the households live in villages randomly assigned to the treatment group where i -PUSH will be implemented after the baseline, while the other half of the households live in control village where i -PUSH will not be implemented until after the endline. The study protocol was reviewed and approved by the AMREF Ethical and Scientific Review Board. Research permits were obtained from the National Commission for Science, Technology and Innovation agency of Kenya. Discussion People in low-and middle-income countries often suffer from high out-of-pocket healthcare expenditures, which, in turn, impede access to quality health services. Saving for healthcare as well as enrolment in health insurance can improve access to healthcare by building capacities at all levels—individuals, families, and communities. Notably, i -PUSH fosters savings for health care through the mobile-phone based “health wallet,” it enhances enrolment in subsidized health insurance through the mobile platform—M-TIBA—developed by PAF, and it seeks to improve health knowledge and behavior through community health volunteers (CHVs) who are trained using the LEAP tool—AMREF’s mHealth platform. The findings will inform stakeholders to formulate better strategies to ensure access to Universal Health Coverage in general, and for a highly vulnerable segment of the population in particular, including low-income mothers and their children. Trial registration Registered with Protocol Registration and Results System (protocol ID: AfricanPHRC; trial ID: NCT04068571 : AEARCTR-0006089 ; date: 29 August 2019) and The American Economic Association’s registry for randomized controlled trials (trial ID: AEARCTR-0006089; date: 26 June 2020).

Treatment outcomes for acute malnutrition can be improved by integrating treatment into community case management (iCCM). However, little is known about the cost‐effectiveness of this integrated nutrition intervention. The present study investigates the cost‐effectiveness of treating moderate acute malnutrition (MAM) through community health volunteer (CHV) and integrating it with routine iCCM. A cost‐effectiveness model compared the costs and effects of CHV sites plus health facility‐based treatment (intervention) with the routine health facility‐based treatment strategy alone (control). The costing assessments combined both provider and patient costs. The cost per DALY averted was the primary metric for the comparison, on which sensitivity analysis was performed. Additionally, the integrated strategy's relative value for money was evaluated using the most recent country‐specific gross domestic product threshold metrics. The intervention dominated the health facility‐based strategy alone on all computed cost‐effectiveness outcomes. MAM treatment by CHVs plus health facilities was estimated to yield a cost per death and DALY averted of US $ 8743 and US$397, respectively, as opposed to US $ 13,846 and US$637 in the control group. The findings also showed that the intervention group spent less per child treated and recovered than the control group: US $ 214 versus US$270 and US $ 306 versus US$485, respectively. Compared with facility‐based treatment, treating MAM by CHVs and health facilities was a cost‐effective intervention. Additional gains could be achieved if more children with MAM are enrolled and treated. Key messages Treatment of MAM by CHVs and health facilities involved a lower cost compared with the health facility‐based treatment approach alone. Treatment of MAM by CHVs and health facilities was cost‐effective compared with the health facility‐based treatment approach alone. Greater health and economic gains could be realized if more children with MAM are enrolled and treated by CHVs through the integration of acute malnutrition treatment into iCCM.

ObjectiveTo determine the prevalence of health insurance and associated factors among households in urban slum settings in Nairobi, Kenya.DesignThe data for this study are from a cross-sectional survey of adults aged 18 years or older from randomly selected households in Viwandani slums (Nairobi, Kenya). Respondents participated in the Lown scholars’ study conducted between June and July 2018.SettingThe Lown scholars’ survey was nested in the Nairobi Urban Health and Demographic Surveillance System in Viwandani slums in Nairobi, Kenya.ParticipantsA total of 300 randomly sampled households participated in the survey. The study respondents comprised of either the household head, their spouses or credible adult household members.Primary outcome measureThe primary outcome of this study was enrolment in a health insurance programme. The households were classified into two groups: those having at least one member covered by health insurance and those without any health insurance cover.ResultsThe prevalence of health insurance in the sample was 43%. Being unemployed (adjusted OR (aOR) 0.17; p<0.05; 95% CI 0.06 to 0.47) and seeking care from a public health facility (aOR 0.50; p<0.05; 95% CI 0.28 to 0.89) was significantly associated with lower odds of having a health insurance cover. The odds of having a health insurance cover were significantly lower among respondents who perceived their health status as good (aOR 0.62; p<0.05; 95% CI 1.17 to 5.66) and those who were unsatisfied with the cost of seeking primary care (aOR 0.34; p<0.05; 95% CI 0.17 to 0.69).ConclusionsHealth insurance coverage in Viwandani slums in Nairobi, Kenya, is low. As universal health coverage becomes the growing focus of Kenya’s ‘Big Four Agenda’ for socioeconomic transformation, integrating enabling and need factors in the design of the national health insurance package may scale-up social health protection.

Sub-Saharan Africa (SSA) experiences an acute dearth of well-trained and skilled researchers. This dearth constrains the region’s capacity to identify and address the root causes of its poor social, health, development, and other outcomes. Building sustainable research capacity in SSA requires, among other things, locally led and run initiatives that draw on existing regional capacities as well as mutually beneficial global collaborations. This paper describes a regional research capacity strengthening initiative—the African Doctoral Dissertation Research Fellowship (ADDRF) program. This Africa-based and African-led initiative has emerged as a practical and tested platform for producing and nurturing research leaders, strengthening university-wide systems for quality research training and productivity, and building a critical mass of highly-trained African scholars and researchers. The program deploys different interventions to ensure the success of fellows. These interventions include research methods and scientific writing workshops, research and reentry support grants, post-doctoral research support and placements, as well as grants for networking and scholarly conferences attendance. Across the region, ADDRF graduates are emerging as research leaders, showing signs of becoming the next generation of world-class researchers, and supporting the transformations of their home-institutions. While the contributions of the ADDRF program to research capacity strengthening in the region are significant, the sustainability of the initiative and other research and training fellowship programs on the continent requires significant investments from local sources and, especially, governments and the private sector in Africa. The ADDRF experience demonstrates that research capacity building in Africa is possible through innovative, multifaceted interventions that support graduate students to develop different critical capacities and transferable skills and build, expand, and maintain networks that can sustain them as scholars and researchers.

Exclusive breastfeeding (EBF) during the first 6 months of life is crucial for optimizing child growth, development and survival, as well as the mother's wellbeing. Mother's employment may hinder optimal breastfeeding, especially in the first 6 months. We assessed the effectiveness of a baby‐friendly workplace support intervention on EBF in Kenya. This pre‐post intervention study was conducted between 2016 and 2018 on an agricultural farm in Kericho County. The intervention targeted pregnant/breastfeeding women residing on the farm and consisted of workplace support policies and programme interventions including providing breastfeeding flexi‐time and breaks for breastfeeding mothers; day‐care centres (crèches) for babies near the workplace and lactation centres with facilities for breast milk expression and storage at the crèches; creating awareness on available workplace support for breastfeeding policies; and home‐based nutritional counselling for pregnant and breastfeeding women. EBF was measured through 24‐h recall. The effect of the intervention on EBF was estimated using propensity score weighting. The study included 270 and 146 mother–child dyads in the nontreated (preintervention) group and treated (intervention) group, respectively. The prevalence of EBF was higher in the treated group (80.8%) than in the nontreated group (20.2%); corresponding to a fourfold increased probability of EBF [risk ratio (RR) 3.90; 95% confidence interval (CI) 2.95–5.15]. The effect of the intervention was stronger among children aged 3–5 months (RR 8.13; 95% CI 4.23–15.64) than among those aged <3 months (RR 2.79; 95% CI 2.09–3.73). The baby‐friendly workplace support intervention promoted EBF especially beyond 3 months in this setting.