Stephen Mulupi

Background Tuberculosis (TB) remains a public health concern despite the massive global efforts towards ending TB. Kenya is among the high burdened countries globally with the TB prevention and care efforts hampered by poor health systems, resource limitations and other socio-political contexts that inform policy and implementation. Notably, TB cases are much higher in men than women, and therefore, the political economy analysis study provides in-depth contexts and understanding of the gender gaps to access and successful treatment for TB infection. Methods The Political Economy Analysis (PEA) adopted a qualitative in-depth approach that targeted 16 Key Informant Interviews (KIIs). The Key Informant Interviews (KIIs) were distributed among government entities, academia, non-state actors, and community TB groups. Results The themes identified were mapped onto the applied PEA analysis framework domains. The contextual and institutional issues included gender concerns related to the disconnect between TB policies and gender inclusion aspects, such as low prioritization for TB programs, limited use of evidence to inform decisions and poor health system structures. The broad barriers influencing the social contexts for TB programs were social stigma and cultural norms such as traditional interventions that negatively impact health-seeking behaviors. The themes around the economic situation were poverty and unemployment, food insecurity, and malnutrition. The political context centered around the systemic and governance gaps in the health system from the national and devolved health functions. Conclusion Overall, broad contextual factors identified from the political economy analysis widens the disparity in targeted gender efforts toward men. Following the development of effective TB policies and strategies, it is important to have well-planned gendered responsive interventions with a clear implementation plan and monitoring system to enhance access to TB prevention and care. Strength and limitations The study provides insights into the political, economic, and social contexts influencing TB prevention and care efforts. Additionally, to the best of our knowledge, this will be the first PEA to evaluate the TB program from a gendered perspective. As a limitation, the study is missing the voices and lived experiences of men leaving with TB as this was not part of the study scope. As such, we do not have their perspectives as they may better articulate some barriers faced with access and uptake of TB prevention and management programs.

Kenya has progressed towards implementing and institutionalizing strategic health purchasing (SHP) practices as a key strategy to achieving universal health coverage (UHC). However, multiple challenges are faced such as fragmentation of pooling arrangements, inadequate health funding, rigid public financial management requirements, lack of purchaser-provider split and lack of formal policies and laws to support SHP. Given these challenges, we conducted a mixed methods study to understand key lessons on the purchasing reforms in Kenya. We conducted a comprehensive literature review of policy documents, white papers, and published articles and reports, and interviewed 12 technical experts and key policy makers. Kenya has established structures for coordination of strategic purchasing for benefit packages designs, contracting of health providers and institutional arrangements. There has been good progress in reforming in the National Health Insurance Fund (NHIF), the main vehicle for the UHC scheme. Although policy and legal frameworks to support this coordination exists, the implementation remains fragmented and poor. Additional continued challenges include unclear regulatory frameworks for NHIF, gaps in monitoring outcomes and performance indicators, and limited data sharing between public and private sector health insurance schemes. There is a need to leverage existing coordinating mechanisms to ensure alignment of SHP to support UHC scale-up and implementation in Kenya.

Objectives Chronic respiratory diseases (CRD) are among the top four non-communicable diseases globally. They are associated with poor health and approximately 4 million deaths every year. The rising burden of CRD in low/middle-income countries will strain already weak health systems. This study aimed to explore the perspectives of healthcare workers and other health policy stakeholders on the barriers to effective diagnosis and management of CRD in Kenya, Malawi, Sudan, Tanzania and Uganda. Study design Qualitative descriptive study. Settings Primary, secondary and tertiary health facilities, government agencies and civil society organisations in five sub-Saharan African countries. Participants We purposively selected 60 national and district-level policy stakeholders, and 49 healthcare workers, based on their roles in policy decision-making or health provision, and conducted key informant interviews and in-depth interviews, respectively, between 2018 and 2019. Data were analysed through framework approach. Results We identified intersecting vicious cycles of neglect of CRD at strategic policy and healthcare facility levels. Lack of reliable data on burden of disease, due to weak information systems and diagnostic capacity, negatively affected inclusion in policy; this, in turn, was reflected by low budgetary allocations for diagnostic equipment, training and medicines. At the healthcare facility level, inadequate budgetary allocations constrained diagnostic capacity, quality of service delivery and collection of appropriate data, compounding the lack of routine data on burden of disease. Conclusion Health systems in the five countries are ill-equipped to respond to CRD, an issue that has been brought into sharp focus as countries plan for post-COVID-19 lung diseases. CRD are underdiagnosed, under-reported and underfunded, leading to a vicious cycle of invisibility and neglect. Appropriate diagnosis and management require health systems strengthening, particularly at the primary healthcare level.

Background: Chronic lung diseases are among the top four non communicable diseases (NCDs), associated with 80% of premature mortality worldwide, debilitating health, and poor quality of life for survivors. Common risk factors for lung diseases include exposure to biomass fuels, environmental pollution, tobacco smoke, hereditary factors, and lower respiratory tract infections. Low-and-middle-income countries bear the biggest burden of chronic lung diseases, due to increasing exposures to risk factors, and weak health systems.To manage this rising threat, countries need to orient their systems towards chronic disease management, strengthen their primary healthcare systems even as they pursue universal health coverage reforms. This paper draws on the views and experiences of health systems actors to explore the current challenges to improving high quality, accessible care for chronic lung diseases. Methods: We explored the perspectives of policy stakeholders on management of chronic lung diseases in five Sub-Saharan African countries, Kenya, Malawi, Sudan, Tanzania, and Uganda. Data were collected between May 2018 and March 2019 through key informant interviews and in-depth interviews with government officials, representatives of non-governmental organizations supporting various health system functions, and healthcare workers of 36 healthcare facilities. Data were analysed using the framework approach. Findings: We identified intersecting vicious cycles of neglect of chronic lung health at both the strategic policy level and the healthcare facility level. At strategic policy level, low diagnostic capacity, weak recording and reporting systems limit the availability of reliable data on the burden of disease, which negatively affects inclusion in policy, and in turn budgetary allocations for diagnostic equipment, training, and medicines. At the service level, lack of budgetary allocations for equipment and training of staff, constrains diagnostic capacity, which, along with limited availability of appropriate medicines reduces service delivery quality and collection of appropriate data within healthcare facilities. These vicious cycles leave health systems ill equipped to respond to the rising burden of chronic lung disease, an issue that has been brought into sharp focus as countries plan for dealing with post COVID lung disease. Interpretation: 1. There is increasing recognition among policymakers that NCDs, including CLD are rising in LMICs. 2. CLDs are under-diagnosed, under-reported and underfunded leading to a vicious cycle of invisibility and neglect at all levels of the health system. 3. Appropriate diagnosis and CLD management require strengthening of the health systems, particularly at the primary healthcare level. Funding Statement: This research was funded by the National Institute for Health Research (NIHR (IMPALA, grant reference 16/136/35) using UK aid from the UK Government to support global health research. Declaration of Interests: None declared. Ethics Approval Statement: The Liverpool School of Tropical Medicine Ethics Committee approved these studies separately (Kenya: protocol 18-054; Uganda: protocol 18-037; Malawi: protocol M1803; Tanzania and Sudan; protocol 18-043). Additionally, each approved was by in-country committees.

Summary: Background: Purchasing in health care financing refers to the transfer of pooled funds to health care providers for the provision of health care services. There is limited empirical work on purchasing arrangements and what is required for strategic purchasing in low‐ and middle‐income countries. We conducted this study to critically assess the purchasing arrangements of the county departments of health (CDOH) who are the largest purchasers of health care in Kenya.Methods: We used a qualitative case study approach to assess the extent to which the purchasing actions of the CDOH in Kenya were strategic. We purposively sampled 10 counties and collected data using in‐depth interviews (n = 81), focus group discussions (n = 4), and documents review. We analyzed data using a framework approach.Results: County departments of health did not practice strategic purchasing. The government's (national and county) role as a steward for the purchasing function was characterized by poor accountability and inadequate budgetary allocations for service delivery. The absence of a purchaser‐provider split between the CDOH and public health care providers undermined provider selection based on performance and quality. Poor public participation and ineffective complaints and feedback mechanisms limited public accountability and responsiveness to the needs of the people.Conclusion: Our findings show that while there are frameworks that could promote strategic purchasing of the CDOH, strategic purchasing is impaired by poor implementation of these frameworks and the inherent weaknesses of a public integrated purchasing system that lacks purchaser‐provider split.

Background: Health insurance is currently being considered as a mechanism for promoting progress to universal health coverage (UHC) in many African countries. The concept of health insurance is relatively new in Africa, it is hardly well understood and remains unclear how it will function in countries where the majority of the population work outside the formal sector. Kenya has been considering introducing a national health insurance scheme (NHIS) since 2004. Progress has been slow, but commitment to achieve UHC through a NHIS remains. This study contributes to this process by exploring communities’ understanding and perceptions of health insurance and their preferred designs features. Communities are the major beneficiaries of UHC reforms. Kenyans should understand the implications of health financing reforms and their preferred design features considered to ensure acceptability and sustainability. Methods: Data presented in this paper are part of a study that explored feasibility of health insurance in Kenya. Data collection methods included a cross-sectional household survey (n = 594 households) and focus group discussions (n = 16). Results: About half of the household survey respondents had at least one member in a health insurance scheme. There was high awareness of health insurance schemes but limited knowledge of how health insurance functions as well as understanding of key concepts related to income and risk cross-subsidization. Wide dissatisfaction with the public health system was reported. However, the government was the most preferred and trusted agency for collecting revenue as part of a NHIS. People preferred a comprehensive benefit package that included inpatient and outpatient care with no co-payments. Affordability of premiums, timing of contributions and the extent to which population needs would be met under a contributory scheme were major issues of concern for a NHIS design. Possibilities of funding health care through tax instead of NHIS were raised and preferred by the majority. Conclusion: This study provides important information on community understanding and perceptions of health insurance. As Kenya continues to prepare for UHC, it is important that communities are educated and engaged to ensure that the NHIS is acceptable to the population it serves.

There is general consensus internationally that unfair distribution of the benefits of research is exploitative and should be avoided or reduced. However, what constitutes fair benefits, and the exact nature of the benefits and their mode of provision can be strongly contested. Empirical studies have the potential to contribute viewpoints and experiences to debates and guidelines, but few have been conducted. We conducted a study to support the development of guidelines on benefits and payments for studies conducted by the KEMRI-Wellcome Trust programme in Kilifi, Kenya.

Samson Muchina Kinyanjui and colleagues from the KEMRI-Wellcome Trust Research Programme discuss how they modified their informed consent processes by taking into account local social, cultural, and economic contexts in the design and administration of consent forms.