Abstract

BackgroundDuring the millennium development goals period, reduction in under-five mortality (U5M) and increases in child health intervention coverage were characterised by sub-national disparities and inequities across Kenya. The contribution of changing risk factors and intervention coverage on the sub-national changes in U5M remains poorly defined.MethodsSub-national county-level data on U5M and 43 factors known to be associated with U5M spanning 1993 and 2014 were assembled. Using a Bayesian ecological mixed-effects regression model, the relationships between U5M and significant intervention and infection risk ecological factors were quantified across 47 sub-national counties. The coefficients generated were used within a counterfactual framework to estimate U5M and under-five deaths averted (U5-DA) for every county and year (1993–2014) associated with changes in the coverage of interventions and disease infection prevalence relative to 1993.ResultsNationally, the stagnation and increase in U5M in the 1990s were associated with rising human immunodeficiency virus (HIV) prevalence and reduced maternal autonomy while improvements after 2006 were associated with a decline in the prevalence of HIV and malaria, increase in access to better sanitation, fever treatment-seeking rates and maternal autonomy. Reduced stunting and increased coverage of early breastfeeding and institutional deliveries were associated with a smaller number of U5-DA compared to other factors while a reduction in high parity and fully immunised children were associated with under-five lives lost. Most of the U5-DA occurred after 2006 and varied spatially across counties. The highest number of U5-DA was recorded in western and coastal Kenya while northern Kenya recorded a lower number of U5-DA than western. Central Kenya had the lowest U5-DA. The deaths averted across the different regions were associated with a unique set of factors.ConclusionContributions of interventions and risk factors to changing U5M vary sub-nationally. This has important implications for targeting future interventions within decentralised health systems such as those operated in Kenya. Targeting specific factors where U5M has been high and intervention coverage poor would lead to the highest likelihood of sub-national attainment of sustainable development goal (SDG) 3.2 on U5M in Kenya.

Highlights

  • During the millennium development goals period, reduction in under-five mortality (U5M) and increases in child health intervention coverage were characterised by sub-national disparities and inequities across Kenya

  • The best model based on information criterion and out of sample predictive accuracy included health facility deliveries, mothers with high parity, fully immunised status, households with access to better sanitation, proportion of children seeking treatment after fever, human immunodeficiency virus (HIV) and malaria infection prevalence, infants’ breastfeeding within the first hour of birth, proportion of stunted children and maternal autonomy

  • Adjusted regression model Early breastfeeding, access to better sanitation, fever treatment-seeking, maternal autonomy, facility deliveries and high parity were associated with a decrease in Under-five mortality (U5M) while HIV and malaria infection prevalence were associated with an increase in U5M (Table 2)

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Summary

Introduction

During the millennium development goals period, reduction in under-five mortality (U5M) and increases in child health intervention coverage were characterised by sub-national disparities and inequities across Kenya. The impact of sub-national intervention coverage, distribution of resources, healthcare utilisation and disease infection on the spatio-temporal disparities observed in U5M has not been adequately defined [9,10,11,12,13]. This limits application of subnationally targeted interventions for public health planning and attainment of child health development goals. In Kenya, such analyses focusing on inequities in child health have previously been conducted [4,5,6, 19,20,21,22,23,24]

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