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    • br In a detailed analysis using multiple data sources in

    2019-04-23


    In a detailed analysis using multiple data sources in this issue of , Emily Keats and colleagues show that Kenya made some progress in reducing maternal and newborn mortality between 2003 and 2015, and made greater progress in reducing child mortality between 1998 and 2015, after earlier increases in mortality. Their analysis is useful because it also shows variations by region and by wealth quintile of key intervention coverage along the continuum of care for mothers, babies, and children. These innovative equity analyses will enable the Kenyan Government to improve their geographical and socioeconomic targeting of these vital interventions. Work on the political and logistical feasibility of such targeting is now urgently needed to make pro-poor policies and their effective implementation a reality, and to make progress towards achieving maternal, neonatal, and child mortality targets within the in Kenya. As other human development indicators also improve—notably, female literacy and the associated later first birth, greater birth intervals, and higher socioeconomic status, all of which are associated with lower mortality—further gains can be expected. Results from the multivariable analyses by Keats and colleagues highlight the roles of such distal determinants, but what are immediately policy-relevant to the acceleration of mortality Paclitaxel (especially maternal deaths, stillbirths, and neonatal deaths, which lag behind child mortality) are the proximal determinants of quality of care during labour and delivery. Although the Lives Saved Tool analyses also highlight the role of skilled birth attendance, Keats and colleagues are unable to explore quality of care in detail because the required information about the content, timing, and manner of patient–provider contacts is unavailable. Efforts to routinely measure quality of care are being developed and need to be integrated into national systems, along with institutionalisation of quality improvement methods in pre-service training, routine practice, and supportive supervision. There also needs to be increased funding for and use of implementation science and systems research, to ensure that intervention coverage is translated into quality care. Notably, skilled birth attendance was also found by Keats and colleagues to be one of the most inequitable coverage indicators, remaining so in 2014. In Kenya, as a proportion of total health expenditure has decreased from approximately 42–50% during 1996–2010 to approximately 26% during 2012–14. In view of the remaining inequity in skilled birth attendance and other coverage indicators, and out-of-pocket expenditure being a barrier to accessing available care, further improvements towards equitable financing are needed, along with efforts to improve quality. Community interventions also need to be scaled up to ensure timely access to both community-based and facility-based care, and community health workers need to be formally integrated into and paid by the government health system in Kenya. The current crisis of low morale and widespread strikes by nurses and doctors in Kenya highlights that the Government needs to urgently reconsider its approach to the public sector health workforce in the country if both quality and equity are to be achieved and further progress made. The Kenya Countdown to 2015 country case study, one of ten, will enable the Government to take stock and plan for the future, to address identified gaps in health systems and policies, financing, and equitable coverage of key interventions. The Countdown to 2015 initiative has done a good job of tracking the progress on maternal, newborn, and child health indicators towards meeting the Millennium Development Goals, and now Countdown to 2030 is continuing this vital work, with an expanded focus, towards achieving the SDGs. The SDG period presents many opportunities for improved and coordinated measurement and tracking in Kenya—such as the Health Data Collaborative—and greater financing and concerted action, towards achieving SDG targets.