Boniface Oyugi

Background In 2013, Kenya removed user fees for delivery in public health facilities; in 2017, the free maternity policy (FMP; Linda Mama) moved to the National Hospital Insurance Fund (NHIF). This study assessed the extent and drivers of women’s out-of-pocket (OOP) payments for delivery under the FMP and how mothers paid for them. Methods We conducted a convergent parallel mixed-methods study in three public hospitals in Kiambu County, Kenya, between November 2018 and June 2019. We held exit interviews (EIs) with 553 mothers after delivery, nine focus group discussions (FGDs) with mothers attending postnatal visits, and 21 in-depth interviews (IDIs) with county officials and healthcare workers. Quantitative data were analysed using descriptive statistics, analysis of variance and log-linear regression, and qualitative data using thematic analysis, and the two were integrated at interpretation. Results Of the 550 mothers analysed, 541 (98.4%) made OOP payments. Mean OOP payments were 9.50 USD (SD 8.20) for normal delivery and 10.88 USD (SD 15.16) for caesarean section. Transport was the largest cost. Other drivers were stock-outs of supplies, ultrasound scans, staff who were unclear about the policy, and late notification of the NHIF. On average, payments were 5.2% of monthly household income, below the 10% threshold for catastrophic expenditure, but at least 18% for mothers in the lowest income group. Most mothers relied on donations from family and friends (63%) or their own savings (35%). No patient characteristics were associated with the amount paid. Conclusions OOP payments during childbirth remain common under Kenya’s FMP and place a burden on households, particularly the poorest. The benefit package should be clearly communicated to mothers and health workers; the medicines and supplies used in maternity care should be reliably stocked, or the FMP sustainably financed; and sustainable emergency transport should be developed with partners.

The rollout of COVID-19 vaccines marked a turning point in pandemic control, yet vaccine hesitancy emerged as a significant obstacle in sub-Saharan Africa (SSA). The study aims to investigate socio-behavioural drivers of vaccine hesitancy in three high-resistance countries: the Republic of Congo, the Democratic Republic of the Congo, and the Republic of Guinea-Bissau. By employing a qualitative ethnographic design, in the period from April to October 2022, the study enrolled 752 participants in semi-structured in-depth interviews and focus group discussions, involving community leaders, women’s leaders, healthcare providers, traditional practitioners, traditional leaders, drivers, and youth leaders, ensuring diverse perspectives. Findings indicate that vaccine hesitancy is fluid and contextual with three principal drivers: (1) denial of COVID-19’s existence, often reinforced by scepticism among healthcare providers and the belief that the disease is foreign or a governmental scheme for financial gain; (2) misinformation, including rumours about vaccine incompatibility with certain foods, and fears of sterility and witchcraft; (3) a firm reliance on traditional medicine, seen as effective alternative to biomedical interventions. Vaccine hesitancy can only be addressed through culturally responsive, multisectoral approaches centred on community dialogue, improved communication, and the integration of trusted networks. Without inclusive strategies, resistance will undermine pandemic response and future health interventions in SSA.

This article investigates the underlying causes of COVID-19 vaccine hesitancy in three sub-Saharan African countries: the Republic of Congo, the Democratic Republic of the Congo (DRC), and Guinea-Bissau. Employing a qualitative ethnographic design, the study engaged 752 participants, including healthcare professionals, community mem-bers, traditional practitioners, and various local leaders, through semi-structured inter-views and focus group discussions. Findings indicate that vaccine hesitancy is fluid and contextual with three principal drivers: (1) denial of COVID-19’s existence, often rein-forced by skepticism among healthcare workers and the belief that the disease is foreign or a governmental scheme for financial gain; (2) misinformation, including rumors about vaccine incompatibility with certain foods, and fears of sterility and witchcraft; and (3) a firm reliance on traditional medicine, seen as effective alternative to biomedical inter-ventions. The study highlights the significant role of inconsistent public health messaging and conspiracy theories in fueling resistance to vaccination. It reflects the necessity of a multisectoral approach that integrates government, health authorities, anthropologists, and other social scientists, as well as community leaders, to foster trust and improve vaccine acceptance. Enhanced education, transparent risk communication, and culturally sensitive community engagement and dialogue are recommended as critical strategies to counter misinformation and build public confidence. While the study’s multidisciplinary and multi-country scope strengthens its conclusions, it only included three countries and provided limited socio-demographic data about the participants. Ultimately, overcoming vaccine hesitancy in these settings requires addressing both historical and contemporary distrust, as well as integrating traditional health systems into public health strategies

Aim: This study explored the enablers and challenges influencing the performance of community health volunteers (CHVs) in Machakos County, Kenya, during the COVID-19 pandemic. Background: The COVID-19 pandemic disrupted healthcare systems globally, with particularly severe impacts in developing countries. Community health workers (CHWs) played a critical role in crisis communication, community engagement, case detection, referrals, and maintaining care continuity. However, limited evidence exists on the factors enabling and hindering their performance during the pandemic. Methods: This study employed a convergent mixed-methods design, integrating focus group discussions (FGDs), in-depth interviews (IDIs), and structured data extraction from the Kenya Health Information System (KHIS). Analysis of the data was guided by Agarwal et al.’s conceptual framework for measuring community health workforce performance with the quantitative data being analyzed using descriptive statistics, while qualitative data being analyzed through thematic analysis. Findings: CHVs effectively disseminated COVID-19 information, addressed vaccine hesitancy, and mobilized communities, supported by training, supervision, and community recognition. Their efforts led to significant improvements in healthcare services, including increased household visits, immunizations, and maternal health referrals. Despite their contributions, CHVs faced challenges such as delayed stipends, limited resources, and occasional community stigma, which hindered performance. Social support networks, community appreciation, and priority healthcare access emerged as key enablers, fostering resilience and motivation. Improved reporting mechanisms also highlighted CHVs’ expanded roles during the pandemic. Conclusion: This study underscores the critical role of CHVs in sustaining healthcare services during the COVID-19 pandemic, despite facing financial, logistical, and social barriers. Their resilience and adaptability led to significant improvements in key health services, supported by effective supervision and training. Strengthening systemic support, integrating CHVs into long-term strategies, and enhancing community recognition are essential to maximize their impact in future health challenges.

Sedentary lifestyle is a major risk factor for cardiovascular diseases (CVDs) which account for 8% of Kenya’s non-communicable disease (NCD) burden. Prevalence of physical inactivity remains high globally. There is paucity of data on physical activity levels in rural Sub-Saharan Africa to inform effective interventions. This study sought to establish levels and factors associated with physical activity in a rural population in Kenya. This was a cross-sectional study in Vihiga, a predominantly rural County in Kenya. Participants were adults aged ≥18 years drawn from four community markets. Stratified sampling by ecological zones and rural/urban status was used to select the four markets and Sampling the Next Customer Exiting the Market method for the respondents. Researcher administered e-questionnaire adapted from International Physical Activity Questionnaire (IPAQ) was used to collect data. Physical activity was calculated as the sum of all Metabolic Equivalents (MET)-minutes/week. Multivariable binary logistic regression analysis was used to identify correlates of physical activity. Out of the total 375 (m: 49%; f: 51%) participants, 27% were physically inactive (m: 22%; f: 32%;) and 42% engaged in low level physical activity. Majority of the respondents (75.5%) engaged in transportation-related physical activity while 32% engaged in leisure physical activities. The odds of being physically inactive were 1.93 times higher for females, 2.62 higher for those aged ≥65 years, and 3.62 higher for those with high health literacy. 48% with high health literacy were in the early working age group (15–24 years). Majority (53%) received health information from healthcare workers, especially for the 60% physically inactive participants. This study highlights the need for targeted community interventions to address the observed physical inactivity especially among women and older adults in rural Kenya.

An explosion at a fuel depot in the region of Berkadzor, around 6 km near Stepanakert in Nagorno-Karabakh, happened on September 25, 2023 resulting in more than 220 lost lives and around 300 injuries. The Ministry of Health of the Republic of Armenia (MoH), collaborating with the WHO, requested assistance for burn specialised care teams and medical evacuation. To describe the emergency response learnings by reflecting on Armenia’s experience managing the incident and the international EMTs’ role in responding to it. This was an observational study whose data was compiled through a triangulation of data obtained from the EMT teams using information management tools, including an EMT Minimum Data Set (MDS) specifically designed for coordinating burns responses in a daily reporting format and others from the MoH and medical evacuation (Medevac) teams, together with the information and analysis from field coordination meetings and deliberation with MoH. Four international EMTs (I-EMTs) were deployed to Armenia in coordination with the MoH and WHO. They were well-prepared and self-sufficient, but the response highlighted the need for standardized protocols for Medevac and burns care. Nearly half of the patients were critical on the first day, with 58% in non-ICU centers and 42% in ICU, with 20 patients medically evacuated using draft Medevac guidelines. Severely burned patients in non-ICU units received 24-hour care from intensive care specialists. However, the shortage of ICU and specialized burns beds in Armenian hospitals was evident. The Emergency Medical Teams Coordination Cell (EMTCC) team effectively used information management tools to collect, process, analyze, and disseminate data to the MoH and response teams, facilitating rapid deployment and decision-making. The EMTs collaborated with local hospital staff, ensuring coordination with MoH and hospital management for follow-up and supply delivery. This integrated approach built local capacity, developed essential rehabilitation modules for burned patients, and delivered burn kits and surgical equipment. Early international assistance, coordinated by WHO and MoH, facilitated a rapid response, early EMT CC installation, and improved communication, ensuring the delivery of essential burn kits. There is a need to set standards for elements such as Medevac and burns care through the WHO EMT Standards and recommendations. In addition, these settings should be integrated into the information management tools under development. The findings and lessons learnt on the specialised care teams have been essential and aligned with the 2030 EMT strategy. Major investments are needed to ensure that more specialised care teams are efficient and effective even in future responses, especially for healthcare facilities that are inadequately capacitated, which would eventually allow local workforce growth and strengthen technical skills through their collaborations in training and collaborative responses. Further, they would guide future fast delivery of surgical equipment and burns treatment kits.

In 2013, Kenya implemented free maternity services, later expanded in 2016 into the ‘Linda Mama’ policy to provide essential health services for pregnant women. This study explored the policy formulation background, processes, content, and actors’ roles in formulation and implementation. Using a convergent parallel mixed-methods case study design, we reviewed documents and conducted in-depth interviews with national stakeholders, county officials, and healthcare workers. We applied a theoretical framework capturing the background and context, processes, content, and actors. The study spanned national, county, and facility levels within Kenya’s health system. Data were audio-recorded, transcribed, and analyzed using a framework thematic approach. Findings showed that political imperatives and global and national goals shaped the expanded policy, drawing on previous learnings. Actor power played a crucial role in shaping policy direction, reflecting their interests and capacity to influence decisions. The policy aimed to improve coverage and administrative efficiency, with NHIF becoming the primary purchaser of services to ensure sustainability and address legal challenges. The policy design, marked by conflicts and time pressures, required a collaborative approach to reconcile design and costing differences. Despite differing interests, discussions and dialogues were essential for leadership and conflict management, culminating in key policy documents. A committee was established for stakeholders to freely discuss and debate the policy design, enabling relevant players to devise solutions and fostering joint commitment for implementation. Government officials, development partners, and representatives significantly influenced policy formulation. Beneficiary representatives had limited awareness of public participation opportunities. National and county actors supported achieving audit, research, financing, and strategic operational goals crucial for policy implementation. In conclusion, this study highlights the continued significance of policy analysis frameworks and theories in understanding the complex nature of policy development. These findings offer valuable insights for countries designing or redesigning healthcare policies and provide relevant information to academic communities.

Objectives The increasing burden of cardiovascular diseases (CVDs) in Kenya threatens its healthcare system. There is a need for innovative models that improve equitable access to CVD prevention services. Community markets are social establishments with untapped potential to promote public health. This is a multiphased feasibility study that explores the potential of Health Kiosks in Markets (HEKIMA) to improve access to CVD prevention services. In this formative phase, the aim was to assess the readiness of primary healthcare centres (HCs) and community markets to jointly deliver CVD prevention services. Design Mixed methods using concept mapping and readiness surveys. Concept mapping with 35 stakeholders from different sectors (health and non-health) to identify feasible priorities for HEKIMA. The readiness questionnaire contained 193 items which were based on the guidance of the WHO Handbook for Monitoring the Building Blocks of Health Systems and adapted to suit the context of a single HC. Setting Vihiga County is located in western Kenya and has a population of 590 013. A total of 18 HCs and 19 markets were assessed, with 10 HCs and 15 markets included in the evaluation. Results 91 statements were generated from concept mapping and distilled into 8 clusters, namely equipment and supplies, access and referral, communication, manpower, networks and linkages, practice, service delivery and health promotion. Agreed actions for HEKIMA were provision of efficient quality services, health promotion and partnerships sensitive to the local context. HCs and markets had established governance systems and basic infrastructure. The majority of the HCs lacked essential CVD medications. No HC–market interface existed but there was willingness for a partnership. Conclusion There was strong consensus that an HC–market interface via community health worker manned kiosks could have a positive impact on health systems, markets and CVD prevention in vulnerable communities. However, significant infrastructural, technical and resource gaps were observed that need to be addressed.

Background: On 5 November 2021, a fire incident following a tanker explosion occurred in the Wellington PMB Junction east of Freetown, Sierra Leone, injuring and killing people. WHO facilitated the deployment of international emergency medical teams (EMTs) to support the Ministry of Health (MoH) in providing care to the wounded in four hospitals. Objective: In this study, we document Sierra Leone's experience managing the fire incident and the role of EMTs in responding to it. Method: This is a cross-sectional After-Action Review (AAR) debrief of the response and deployment, including focus group discussion with WHO and MoH staff (n = 14) in a virtual workshop and document reviews on the response. The results thematically cover the event and the different agencies' responses and a review of EMTs' responses. Results: At the onset of the emergency, the National Disaster Management Agency (NDMA) instituted a well-coordinated response mechanism in collaboration with the MoH and managed all response actions, such as medical services, informing partners and the public and coordinating all other agencies. WHO facilitated EMT deployments and mobilised medical supplies and equipment, while the MoH provided accommodation, logistics and coordination. The EMTs dispensed their functions with professionalism, adapted to the environment and available resources, and augmented the care the national health workers provided. They offered additional care: reconstructive surgery, pain management, palliative care, wound care, rehabilitation, physiotherapy and psychosocial counselling, which were initially inadequate at the onset of the disaster. 94 out of 157 patients were discharged home at the end. National clinicians acquired additional skills through the capacity-building activities of EMTs. The community appreciated the teams. Conclusion: The government, partners and EMTs were important in the response and worked with speed and political acceptability using the context experience to provide surge support to the country. This experience brought to focus the idea of developing a national EMT in Sierra Leone, which would be useful to help respond even more swiftly. In collaboration with WHO, there is a need to institute further mechanisms to facilitate rapid response and quality-assured deployment of EMTs at regional and sub-regional levels and strengthen to support future responses.

Background: The WHO Emergency Medical Teams (EMT) Initiative coordinates the deployment of qualified medical teams who promptly respond to public health emergencies (PHEs) and provide quality service during emergencies whilst strengthening capacity. Globally, 40 EMTs have been classified between 2016 and the present (as of the writing of this article in December 2023) and are from across all the WHO regions except the WHO Africa Region (AFRO). However, WHO Africa has prioritised the implementation of EMTs in 10 priority countries to address the public health emergencies (PHEs) affecting the region.Objective: This article describes the development and progress of national EMTs in the WHO African Region over the past 7 years and elucidates the main lessons learned and the complexity and challenges in the process.Methods: This study employed a case study approach because of its appropriateness in examining a complex social phenomenon in a socio-political context in depth, using multiple lenses simultaneously. Data and information were obtained through document reviews and key informant interviews (KIIs) (n = 5) with the members of the EMT Initiative on shared field experiences. Data were systematically analysed using the Stages of Implementation Completion (SIC) framework, and the lessons learnt were presented using components of a framework from Adini et al.Results: The Initiative commenced in the WHO African Region following its launch in December 2017 in Senegal. The assessments of the concept’s engagement (involved learning and deciding), feasibility (reviewing expectation and capacity), and readiness planning (collaborating and preparing) showed that the context-specific (African context) challenges, lessons from different emergency response actions mainly guided the Initiative’s pre-implementation phase in the region and prompted the WHO emergency leadership on the urgency and need for the EMT concept in the region. The assessment of the implementation processes showed progress in key areas, with staff demonstrating improved competency, EMT services maintaining high fidelity, effective consultation launching critical components, and ongoing services providing successful support and monitoring. Creating the N-EMTs and revitalising the EMT concept required an aligned strategy with other regional emergency programmes and a futuristic vision. Proposed sustainability and governance components include creating N-EMT, developing a coordination structure, collaborating with partners, and finalising the N-EMT.Conclusion: The Initiative is an imperative component that would allow better-targeted management of health emergencies in the region. The continuous refinement of the EMT initiative is crucial. There is a need to work on additional components, such as a context-specific framework for collaborations and partnerships that would enhance deployment and procurement modalities and the complementarity between other regional initiatives to improve the work. Emphasis should be placed on strengthening local health systems, enhancing training and capacity-building programmes, and fostering regional and international collaborations. Additionally, sustainable funding and resource allocation are essential to ensure the resilience of EMTs in the African region and their long-term success.