Gilbert Kokwaro

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.

The coronavirus pandemic (COVID-19) has triggered a public health and economic crisis in both high and low resource settings since the beginning of 2020. With the first case being discovered on 12th March 2020, Kenya has responded using both health and non-health strategies to mitigate the direct and indirect impact of the disease on its population. However, this has had both positive and negative implications for the country's overall health system. This paper aimed to understand the pandemic's impact and develop lessons for future response by identifying the key challenges and opportunities Kenya faced during the pandemic. We conducted a qualitative study with 15 key informants, purposefully sampled for in-depth interviews from September 2020 to February 2021. We conducted direct content analysis of the transcripts to understand the stakeholder's views and perceptions of how COVID-19 has affected the Kenyan healthcare system. The majority of the respondents noted that Kenya's initial response was relatively good, especially in controlling the pandemic with the resources it had at the time. This included relaying information to citizens, creating technical working groups and fostering multisectoral collaboration. However, concerns were raised regarding service disruption and impact on reproductive health, HIV, TB, and non-communicable diseases services; poor coordination between the national and county governments; shortage of personal protective equipment and testing kits, and strain of human resources for health. Effective pandemic preparedness for future response calls for improved investments across the health system building blocks, including; human resources for health, financing, infrastructure, information, leadership, service delivery and medical products and technologies. These strategies will help build resilient health systems and improve self-reliance, especially for Countries going through transition from donor aid such as Kenya in the event of a pandemic.

As more countries move from low- to middle-income status, they are perceived as increasingly capable of financing their own health systems. Some donors have begun to transition their support out of such middle-income countries (MICs) to redirect their funds to countries with greater needs. However, this transition may leave a funding gap for MICs that could be difficult to fill when external resources decline. If not carefully managed, such financial shifts could lead to the loss of health gains that occurred while receiving substantial external financial support. Understanding levels of donor dependency (i.e., whether or not a country is likely to have capacity to fill a funding gap caused by donor transition) and donor concentration (i.e., when only a few donors make up the majority of aid) can illuminate areas of potential vulnerability for transition. In this study, we analyzed Kenya’s health system for donor dependency and donor concentration.

There are several problems associated with treatment of malaria, especially in sub-Saharan Africa: effectiveness, access (financial and physical), safety and tolerability, and adherence. Even in an ideal situation in which the first 3 factors are not a problem, adherence would still be problematic, especially when dealing with rural populations in developing countries, where relief of symptoms of malaria is often interpreted as “cure” and where there is, therefore, great reluctance to continue taking the rest of the medication as prescribed. Adherence has been defined as “the extent to which a patient fulfills the intention of the prescriber in taking medication” [1, p. 7]. Several drug-associated factors may affect adherence [1], including appropriateness of the prescription, side effects, dose regimen, drug presentation and formulation, number of drugs prescribed concurrently, and duration of treatment.

Aims  Phenobarbital is commonly used to treat status epilepticus in resource‐poor countries. Although a dose of 20 mg kg⁻¹ is recommended, this dose, administered intramuscularly (i.m.) for prophylaxis, is associated with an increase in mortality in children with cerebral malaria. We evaluated a 15‐mg kg⁻¹ intravenous (i.v.) dose of phenobarbital to determine its pharmacokinetics and clinical effects in children with severe falciparum malaria and status epilepticus.Methods  Twelve children (M/F: 11/1), aged 7–62 months, received a loading dose of phenobarbital (15 mg kg⁻¹) as an i.v. infusion over 20 min and maintenance dose of 5 mg kg⁻¹ at 24 and 48 h later. The duration of convulsions and their recurrence were recorded. Vital signs were monitored. Plasma and cerebrospinal fluid (CSF) phenobarbital concentrations were measured with an Abbott TDx FLx^® fluorescence polarisation immunoassay analyser (Abbott Laboratories, Diagnostic Division, Abbott Park, IL, USA). Simulations were performed to predict the optimum dosage regimen that would maintain plasma phenobarbital concentrations between 15 and 20 mg l⁻¹ for 72 h.Results  All the children achieved plasma concentrations above 15 mg l⁻¹ by the end of the infusion. Mean (95% confidence interval or median and range for C_max) pharmacokinetic parameters were: area under curve [AUC (0, ∞) ]: 4259 (3169, 5448) mg l⁻¹.h, : 82.9 (62, 103) h, CL: 5.8 (4.4, 7.3) ml kg⁻¹ h⁻¹, V_ss: 0.8 (0.7, 0.9) l kg ⁻¹, CSF: plasma phenobarbital concentration ratio: 0.7 (0.5, 0.8; n= 6) and C_max: 19.9 (17.9–27.9) mg l⁻¹. Eight of the children had their convulsions controlled and none of them had recurrence of convulsions. Simulations suggested that a loading dose of 15 mg kg⁻¹ followed by two maintenance doses of 2.5 mg kg⁻¹ at 24 h and 48 h would maintain plasma phenobarbital concentrations between 16.4 and 20 mg l⁻¹ for 72 h.Conclusions  Phenobarbital, given as an i.v. loading dose, 15 mg kg⁻¹, achieves maximum plasma concentrations of greater than 15 mg l⁻¹ with good clinical effect and no significant adverse events in children with severe falciparum malaria. A maintenance dose of 2.5 mg kg⁻¹ at 24 h and 48 h was predicted to be sufficient to maintain concentrations of 15–20 mg l⁻¹ for 72 h, and may be a suitable regimen for treatment of convulsions in these children.

Brain and plasma concentrations of oxaminiquine were determined following intravenous dosing (15 mg kg-1) in female Wistar rats. Maximum brain concentrations were achieved one hour after dosing and at all sampling times oxamniquine levels were higher in brain tissues compared to the corresponding plasma samples. It is concluded that the reported adverse neurological effects associated with the clinical use of oxaminiquine in man may be due to the passage of sufficiently large quantities of this drug into the CNS.