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Kenya’s Tuberculosis Control Efforts

 

The TWENDE Team at the Kenya Medical Research Institute (KMRI) has authored this analysis. The TWENDE Team at KMRI is led by Dr. Evans Amukoye who is also the TWENDE Country Principal Investigator for Kenya. Within KEMRI Dr. Amukoye is the Chief Research Officer and is currently acting as the Deputy Director (Research and Development). Until 2015, he was the Director for the Centre of Respiratory Diseases Research (CRDR). He has vast research experience especially in the area of paediatric health and has participated in a number of research studies and published widely in the aspects of tuberculosis. He is a founding member of the Pan African Thoracic Society and a co-editor of African journal of Respiratory Medicine. 

The health landscape in Kenya has changed significantly over the past ten years.  Kenya has developed a long-term strategy -Vision 2030, which is an economic blueprint that aims to transform the country from middle-income country to a newly industrialized nation by the year 2030. 

The social pillar component as outlined in the blueprint, seeks health for all citizens through modernization of health facilities and equipping them with the latest diagnostic and imaging equipment among other developments.  

In the year 2013, for a second time, the health sector was among the sectors that were decentralized to regional administrative units referred to as county governments. This resulted to the transfer of functions that include planning, staffing, budgeting and service delivery from national to county governments.  

Kenya is ranked among the 22 high burden tuberculosis (TB) countries that account for more than 80 percent of the world’s TB cases. According to the World Health Organization (WHO) estimates, in the year 2012, Kenya had 120,000 new cases of TB. TB co-infections have been reducing over the years and stood at 35 percent in 2014. 

In addition, the national TB, Leprosy and Lung Disease (NTLD) Program reported that there has been a decline in case notification across in the country (NLTP Report, 2015). Eighty-seven out of 100 patients with co-infection are now on antiretroviral treatment (ART). 

Case fatality among notified TB/HIV co-infected patients was more than double at 10 percent than that in HIV negative TB patients which stood at four percent for patients reported in 2013 (NLTD Report, 2014). Concerted national government efforts and stakeholders have seen a gradual decline in case notification, suggesting that incidences may be declining. 

Currently, over 88 percent of the case detection has been enhanced through community engagement. NTLD has partnered with the private sector health care service providers to intensify case finding. Other strategies include nutritional support, TB/HIV collaborative activities and an increased focus on identifying TB in children. 

The National tuberculosis and leprosy programme (NTLP) in partnership with donor agencies has been rolling-out new molecular-based tools in all public health facilities. Such tools include XpertTM MTB/RIF. Locally available evidence is suggestive that the new diagnostic tools are convenient, user-friendly compared to traditional and conventional methods and shorten time taken for patients to receive the test results. 

Tools such the XpertTM MTB/RIF were approved by WHO to be implemented up to district level hospital but it is not clear to what extent this implementation has been made especially in high TB burden countries like Kenya. In some Kenyan settings where the Xpert machines have been installed, reports indicate sub-optimal performance than what is specified by the original equipment manufacturer. 

Furthermore the shortage of evidence on the cost implications of the new diagnostic tools to the public healthcare service providers as well as savings to patients makes it difficult for policy makers to appreciate the value of the investment and complicates the subsequent prioritisation and allocation of resources to procure new diagnostic tools. This perhaps explains why the National tuberculosis and leprosy detection program will face a financing deficit of nearly Kenya Shillings 21.4 billion in the coming budget.

The translation of research findings into policies remains a challenge especially in Kenya where research evidence is embraced to be important but seldom applied. Engaging policy makers towards defining health related priority research questions and their participation in the process are touted to be the first steps towards effective ownership and subsequent utilization research evidence in policy making. 

There are many diagnostic tools that need adoption. There is need for a strong and comprehensive evidence base to support decision-making with regard to the new and improved diagnostic tools. However, what makes policy makers adopt new technologies, factors that lead to adoption by health workers and user perceptions has not fully documenting in the East Africa region. 

The Tuberculosis: Working to Empower Nations’ Diagnostic Efforts (TWENDE) study will not only elucidate the factors of new technology uptake but also chart the pathway to their nationwide adoption. The general objective of the TWENDE study is to create a platform for accelerating uptake of diagnostic and clinical research innovations into policy and practice through uncovering and addressing the impediments for implementation of health research innovations. 

The TWENDE Kenya Team will use a mixed method study design. The quantitative arm will consist of coded and semi-coded questions that aim at documenting the state of TB diagnosis and treatment in Kenya. A short online survey targets to reach at least 195 TB health offices located in public hospitals’ chest clinics across 47 counties with a view of capturing the general overview of the state of TB diagnosis and treatment in Kenya. 

The survey will be followed with focused healthcare facility (HCF) audits in selected counties and sub-counties to establish the extent of implementation and utilization of TB diagnostic tools and the challenges thereof. 

In the qualitative arm, a total of 30 focus group discussions (FGDs) and 30 key informant interviews (KIIs) will be conducted among health managers, policy actors and stakeholders including private sector to understand the contextual challenges of TB diagnosis and treatment and identify opportunities to overcome these challenges. 

Purposive sampling of the counties will be applied based on security and geographic reach of some public facilities with the aim of covering 31 counties. In a county, the study will aim at covering county referral hospital (equivalent of regional hospital in Uganda and Tanzania) and sub-county hospital (equivalent of district hospital in Uganda and Tanzania). On this basis TWENDE in Kenya has selected to cover 45 hospitals that are located in 31 counties and spread over 10 administrative regions as follows: 

  • Coast Region (3)
  • North-Eastern Region (2)
  • Upper Easter Region (4)
  • Lower Eastern Region (4)
  • Central Region (4)
  • North Rift Region (3)
  • South Rift Region (2)
  • Western Region (3)
  • Nyanza (2)
  • Nairobi (2)

Workshops will be organised to discuss study findings with policy makers and implementers with a view of drawing strategic plan for translating health research innovations into policy and practice. 

The deliverables of the TWENDE study will be providing valuable knowledge on how uptake of research innovations can be accelerated, encouraging new research domains, and strengthening partnerships with policy makers as stakeholders in research and application of research evidence. 

The study will also develop capacity knowledge translation in participating research institutions through equipping and training knowledge transfer officers and regional user groups to sustain the translation of research outputs to public domain and offering expert advice on policy formulation. Field work for the study is expected to commence in July 2016 after getting the necessary ethical and scientific approvals. The study has an expected completion timeline of December 2017.