Edwine Barasa

Typhoid remains endemic in many low and middle-income countries, with the highest incidence reported in children under 15 years. No published study has estimated the cost of hospitalised paediatric typhoid cases in Kenya. This analysis estimated the direct medical, direct non-medical and indirect costs from the healthcare provider and societal perspectives and assessed the proportion of households that would experience catastrophic health expenditure (CHE) due to the disease. Patient-level data on hospitalised children with typhoid were drawn from 16 public hospitals that are part of the Clinical Information Network (CIN) in Kenya. A cost-of-illness analysis was conducted. Resource quantities were extracted from CIN data and unit costs were obtained from price lists, surveys and expert interviews. All costs were converted to 2025 KES and USD. A simulation-based CHE analysis was conducted. One-way sensitivity analysis varied hospital bed, staff, non-medical and indirect costs. Median cost per unique admission was US$79.68 from the provider and US$96.95 from the societal perspective. Staff costs accounted for up to 55% of societal costs while hospital-bed costs accounted for up to 15%. Productivity loss represented 12% of societal costs. Staff time was the most influential parameter in the sensitivity analysis, increasing median costs by up to 89% from the provider and 74% from the societal perspective. CHE incidence rose as the share paid out-of-pocket increased and house wealth declined, with rural households in the lowest wealth quintile most affected. At full out-of-pocket payment, up to 23.6% of rural and 26.5% of urban households from the poorest wealth quintile could face CHE. Typhoid imposes a substantial economic burden among hospitalised children in Kenya, driven mainly by staff and hospital-bed costs. The findings of this study can guide policymakers in reducing strain on health services and the financial burden on families.

Background: Primary healthcare (PHC) is critical towards achieving Universal Health Coverage (UHC). In Ghana, PHC is organised at the district level and plays a key role in the country’s pursuit of UHC. However, many districts face challenges not only with limited resources but also with how effectively they are used. We examined how efficiently districts in Ghana use their health resources and what factors are associated with this efficiency. Methods: We used a two-step stochastic frontier analysis model using data from 181 districts. The output variable was a composite coverage index derived from eight PHC service indicators for 2021, primarily reflecting maternal and child health and infectious disease services. Input variables included district health expenditure for 2020/2021 and the number of health facilities and clinical staff in 2021. We then assessed the associations between efficiency scores generated by the model and health systems, socioeconomic and demographic factors, such as health facility type, insurance coverage, literacy level, Gini coefficient, poverty incidence, urbanisation and population density. Results: On average, districts operated at 87% efficiency, with scores ranging from 65% to 99%. Two factors were associated with the efficiency. First, districts with a higher proportion of PHC facilities tended to use resources more efficiently (coeff=0.151; 95% CI=0.041 to 0.261). Second, districts with greater income inequality were less efficient, measured by the Gini coefficient (coeff=−0.858; 95% CI=−1.146 to −0.252). Conclusion: Districts in Ghana have the potential to improve PHC outputs by about 13% on average by better use of existing resources and addressing determinants of efficiency. Findings suggest that districts with a higher proportion of PHC facilities and lower income inequality tend to be more efficient. These patterns highlight the value of strengthening PHC infrastructure and pursuing equity-focused policies as part of strategies to enhance efficiency in district health systems.

Typhoid remains endemic in many low and middle-income countries, with the highest incidence reported in children under 15 years. No published study has estimated the cost of hospitalized paediatric typhoid cases in Kenya. This analysis estimated the direct medical, direct non-medical, and indirect costs from the healthcare provider and societal perspectives and assessed the proportion of households that would experience catastrophic health expenditure (CHE) due to the disease. Patient-level data on hospitalized children with typhoid were drawn from 16 public hospitals that are part of the Clinical Information Network (CIN) in Kenya. A cost-of-illness analysis was conducted. Resource quantities were extracted from CIN data, and unit costs were obtained from price lists, surveys and expert interviews. All costs were converted to 2025 KES and USD. A simulation-based catastrophic health expenditure analysis was conducted. One-way sensitivity analysis varied hospital bed, staff, non-medical and indirect costs. Median cost per unique admission was USD 79.68 from the provider and USD 96.95 from the societal perspective. Staff costs accounted for up to 55% of societal costs, while hospital-bed costs accounted for up to 15%. Productivity loss represented 12% of societal costs. In the sensitivity analysis, adjusting staff time increased the median cost by 89% for the provider perspective and 74% for the societal perspective. Conversely, varying median daily bed charges between the 25th and 75th percentiles altered the cost of treatment by -9% to 5% for the provider and -5% to 5% for the societal perspectives. CHE incidence rose as the share paid out-of-pocket increased and house wealth declined, mainly impacting rural and poorer households. Typhoid imposes a substantial economic burden among hospitalized children in Kenya, driven mainly by staff and hospital-bed costs. The findings of this study can guide policymakers in reducing strain on health services and the financial burden on families. What is already known on this topic: Typhoid is endemic in Kenya, and although its epidemiology is well described, the economic burden has not been quantified. The gap limits the evidence available to guide financing decisions and investments in prevention strategies. What this study adds: This study provides the first estimate of the economic burden of hospitalised paediatric typhoid in Kenya, identifies key cost drivers, and notable cost differences across geographic settings and patient groups. It also highlights the financial strain that typhoid can place on affected households. How this study might affect research, practice or policy: The study provides researchers with a methodology for assessing catastrophic health expenditure when household level data is not available. The outputs of the study can be used to evaluate the value of vaccines for typhoid in similar contexts. These findings offer policymakers, local evidence to guide decisions for insurance and health financing, especially in settings and patient groups where the financial burden is greatest.

Low-income and middle-income countries (LMICs) are facing an urgent and complex challenge: how to transition to greater self-sustainability in health financing amid declining donor support. While this shift is inevitable, the policy responses it elicits carry significant implications for health system equity and access. This commentary highlights four policy choices increasingly observed in LMICs that we argue are unacceptable in the pursuit of sustainability. These include: (1) shifting the financial burden to out-of-pocket payments; (2) over-reliance on contributory health insurance schemes; (3) displacement of basic primary healthcare services; and (4) abandoning community-based service delivery in favour of facility-centric models, undermining the integrity of people-centred health systems. We argue that while short-term fiscal pressures may push countries towards these decisions, they ultimately erode health gains, exacerbate inequities and threaten progress towards universal health coverage. We call on policymakers to adopt evidence-informed approaches that enhance efficiency, protect the most vulnerable, prioritise public financing and preserve the core values of inclusive and equitable health systems during this critical transition.

Background: Kenya has identified Primary Health Care Networks (PCNs) as a key reform to strengthen Primary Health Care (PHC) delivery and enacted the Primary Health Care Act of 2023 to support their implementation. PCNs were piloted in Kisumu and Garissa counties in 2020 and rolled out nationally in 2023. However, little is known about how PCNs are being implemented across diverse county contexts. This study examined the emergence and implementation experience of the PCN reform in Kenya. Methods: We used a cross-sectional qualitative process evaluation design. We collected data at the national level and in five purposefully selected counties, using in-depth interviews ( n = 65) and document reviews, between February and June 2024. Participants included stakeholders from the national level (Ministry of Health, development and implementing partners, and the Council of Governors), county level (county health departments, sub-county managers, multi-disciplinary team (MDT) members, facility managers, and frontline health workers), and community level (community health committee chairs and community health workers). We reviewed policy documents and county reports on PCN implementation for document review. We analysed the data using a thematic approach. Results: The emergence of PCNs as a policy reform was motivated by a technocratic process that identified underlying challenges in PHC service delivery and proposed PCNs as a solution, as well as political interest and support that facilitated their adoption. The implementation effectiveness of PCNs varied across the study counties, with critical aspects of PCN design, such as the establishment of MDTs and the digitisation of PCNs, being inadequately implemented. The effectiveness of PCNs’ implementation may have been constrained by capacity gaps in key foundational aspects of PHC health systems, including financing, human resources, health commodities, and information systems. Moreover, the implementation effectiveness of PCNs may have been undermined by the limited integration of key health facility functions, including financing, human resource management, health commodity supply chains, information systems, and care coordination. Conclusion: Strengthening PCN implementation in Kenya requires investment in policy capacity to ensure effective implementation. The foundational aspects of PHC systems must be reinforced. The PCN design should be refined to enhance the integration and coordination of key health facility functions.

Background Low-income and middle-income countries, including Kenya, are pursuing universal health coverage (UHC) through the establishment of Social Health Insurance programmes. As Kenya rolls out the recently unveiled UHC strategy that includes a national indigent cover programme, the goal of this study is to evaluate the impact of health insurance subsidy on poor households’ healthcare costs and utilisation. We will also assess the effectiveness and equity in the beneficiary identification approach employed. Methodology and analysis Using a quantitative design with quasi-experimental and cross-sectional methods, our matched cohort study will recruit 1350 households across three purposively selected counties. The ‘exposure’ arm, enrolled in the UHC indigent programme, will be compared with a control arm of eligible but unenrolled households over 12 months. Coarsened exact matching will be used to pair households based on baseline characteristics, analysing differences in expenses and catastrophic health expenditure. A cross-sectional design will be employed to evaluate the effectiveness and equity in beneficiary identification, estimating inclusion errors associated with the subsidy programme while assessing gender equity. Ethics and dissemination Ethical approval has been obtained from the Scientific and Ethics Review Unit at Kenya Medical Research Institute, with additional permissions sought from County Health Departments. Participants will provide written informed consent. Dissemination strategies include peer-reviewed publications, conference presentations and policy-maker engagement for broad accessibility and impact.

Introduction: There is a growing emphasis on improving primary healthcare (PHC) services and granting frontline service providers more decision-making autonomy. In October 2023, Kenya enacted legislation mandating nationwide facility autonomy. There is limited understanding of the effects of health facility autonomy on PHC facilities performance. It is recognised that stakeholder interests influence reforms, and gender plays a critical role in access to health and its outcomes. This protocol outlines the methods for a study that plans to evaluate the effects, implementation experience, political economy and gendered effects of health facility autonomy reforms in Kenya. Methods and analysis: The research will use a before-and-after quasi-experimental study design to measure the effects of the reform on service readiness and service utilisation and a cross-sectional qualitative study to explore the implementation experience, political economy and gendered effects of these reforms. Data to measure the effects of autonomy will be collected from a sample of 80 health facilities and 1600 clients per study arm. Qualitative interviews will involve approximately 83 facility managers and policymakers at the county level, distributed across intervening (36) and planning to intervene (36) counties. Additionally, 11 interviews will be conducted at the national level with representatives from the Ministry of Health, the National Treasury, the Controller of Budget, the Council of Governors, the Auditor General and development partners. Given the uncertainty surrounding the implementation of the reforms, this study proposes two secondary designs in the event our primary design is not feasible—a cross-sectional study and a quasi-experimental interrupted time series design. The study will use a difference-in-difference analysis for the quantitative component to evaluate the effects of the reforms, while using thematic analysis for the qualitative component to evaluate the political economy and the implementation experience of the reforms. Ethics and dissemination: This study was approved by the Kenya Medical Research Institute Scientific and Ethics Review Unit (KEMRI/SERU/CGMR-C/294/4708) and the National Commission for Science, Technology and Innovation (NACOSTI/P/23/28111). We plan to disseminate the findings through publications, policy briefs and dissemination workshops.

In this chapter we apply the everyday health system resilience framework in examining COVID-19 responses over 2020-22 in Kenya (primarily considering national experience) and South Africa (primarily considering experience in the Western Cape province). Set against a background description of country contexts and pandemic governance structures and processes, the chapter analyses both the strategies implemented in response to COVID-19 (the ‘what’ of response, considering public health containment strategies and actions to strengthen health services) and the health system capacities that enabled or constrained these responses (the ‘how’ of response, considering cognitive, behavioural and contextual capacities). Perhaps the weakest area of the COVID-19 response across countries lay at the interface of community and public health and social care. Nonetheless, by 2022 positive system adjustments were noted in both countries that built on past experience and may have enhanced overall health system capability to respond to future challenges. These include a greatly strengthened surveillance capacity; novel leadership practices, including strengthened capacity to use evidence in decision-making; wider sets of learning processes; and a range of strengthened relationships, including inter-sectoral collaboration. Overall, these experiences suggest that pandemic preparedness must embrace efforts to strengthen primary care services and community-level networks, as well as deepen the everyday health system resilience capacities that sustain collective action in response to any challenge.

The everyday health systems resilience framework was initially derived from empirical research undertaken in Kenya and South Africa examining the nature of chronic stress experienced within district health systems, and the locally led responses to such stress. This chapter presents the framework and discusses its core elements by reference to organisational and socio-ecological resilience theory, as well as wider empirical research. Resilience is understood as an emergent process within a complex, adaptive system generated by responding to stress, rather than as an outcome or system goal. Stress responses represent collective actions, developed and implemented by people and teams, and comprise combinations of absorptive, adaptive and/or transformative strategies. Generating, selecting and implementing such collective actions are, moreover, underpinned, or constrained, by the individual-, team- and system-level resources and practices which embody the system’s cognitive, behavioural and contextual capacities. These capacities include resources and practices that might support the inclusion of previously excluded groups, and their experiences, in decision-making, or deepen their exclusion. The capacities may also be transformed through responding to stress in ways that support the system’s responses to future challenges. Applying the framework in analysing empirical experience involves teasing out the strategies and capacities entailed in resilience processes, as well as the resources and practices in which the capacities are embodied. Such analysis offers insights of relevance to: health system strengthening in the face of chronic stress; deepening health system preparedness to respond to acute shocks; and developing systemic approaches to redress power imbalances and promote health system equity.

Background: In 2018, Kenya’s Ministry of Health gazetted the Health Benefits Package Advisory Panel (HBPAP) to develop a benefits package for its Universal Health Coverage (UHC) programme. In this study, we examine the political process that led to the gazettement of the HBPAP. Methods: We conducted a case study based on semi-structured interviews with 20 nationallevel participants and, reviews of documents such as organizational and media reports. We analyzed data from the interviews and documents thematically using the Braun and Clarke’s six step approach. We identified codes and themes deductively using Kingdon’s Multiple Streams Theory which postulates that the successful emergence of a policy follows coupling of three streams: the problem, policy, and politics streams. Results: We found that the problem stream was characterized by fragmented and implicit healthcare priority-setting processes that led to unaffordable, unsustainable, and wasteful benefits packages. A potential policy solution for these problems was the creation of an independent expert panel that would use an explicit and evidence-based healthcare prioritysetting process to develop an affordable and sustainable benefits package. The political stream was characterized by the re-election of the government and the appointment of a new Cabinet Secretary for Health. Coupling of the problem, policy, and political streams occurred INTERNATIONAL JOURNAL OF HEALTH POLICY AND MANAGEMENT (IJHPM) ONLINE ISSN: 2322-5939 JOURNAL HOMEPAGE: HTTPS://WWW.IJHPM.COM 3 during a policy window that was created by the political prioritization of UHC by the newly reelected government. Policy entrepreneurs who included health economists, health financing experts, health policy analysts, and health systems experts leveraged this policy window to push for the establishment of an independent expert panel as a solution for the issues identified in the problem stream. They employed strategies such as forming networks, framing, marshalling evidence and utilizing political connections. Conclusion: Applying Kingdon’s theory in this study was valuable in explaining why the HBPAP policy idea was gazetted. It demonstrated the crucial role of policy entrepreneurs and the strategies they employed to couple the three streams during a favourable policy window. This study contributes to the body of literature on healthcare priority-setting processes with an unusual analysis focused on a key procedural policy for such processes.