BACKGROUND: Kenya rolled out a UHC indigent program aimed to expand financial protection and health service access for poor households through subsidized health insurance under the national insurer, National Health Insurance Fund (NHIF). As Kenya transitions to a new social health insurance framework under the Social Health Authority (SHA), understanding the implementation experience of the UHC indigent program is critical for informing the roll out of SHA’s indigent program. METHODS: We conducted a qualitative process evaluation of the UHC indigent program using document reviews, semi-structured interviews with 23 key informants from national and county health authorities, development partners, and implementing actors, complemented by a validation workshop with 57 stakeholders. Our analysis was guided by Moore et al.‘s process evaluation framework and Wu et al.‘s policy capacity lens, examining implementation fidelity and capacities at multiple levels. RESULTS: The program’s implementation deviated from its original centralized design, with counties exerting control over beneficiary identification due to national data gaps, incomplete rollout of the Harmonized Testing Tool, and political and operational constraints. Variations in targeting methods, reliance on under-resourced community health actors, and delays in biometric registration contributed to partial enrolment, limited access, exclusion errors, and mistrust. Although some counties reported increased service utilization, this was limited by unregistered dependents and lack of beneficiary awareness. Stakeholders expressed concern over SHA’s use of proxy means testing for identifying the poor, citing risks of exclusion, manipulation, and failure to capture locally constructed definitions of poverty. CONCLUSION: Kenya’s experience demostrates the need to align national targeting frameworks with local realities, invest in policy capacity across stakeholders, and prioritize community validation and communication in subsidy programs. As SHA rolls out a new indigent program, these lessons offer critical guidance for enhancing fidelity, equity, and accountability.

ABSTRACT Background Kenya’s facility autonomy reforms are intended to improve health system equity, efficiency, and responsiveness to community needs by shifting decision-making to the frontline. This study evaluates the implementation process and experience of facility autonomy reforms in Kenya post devolution of health services. Methods We conducted a concurrent mixed methods study of counties (n=6) in Kenya, selected based on their implementation of facility financial autonomy reforms as of June 2023. For the quantitative aspect, we assessed 141 randomly selected public health facilities across all levels of service provision. We then did a descriptive analysis to measure the level and perceptions of autonomy. For the qualitative aspect, we reviewed documents and interviewed purposively selected stakeholders (n=71) involved with autonomy reforms at national, county, and facility levels, cutting across health, finance, legal, political and community actors. We analyzed the transcripts thematically using NVivo 12. Results The emergence of the FIF reforms in Kenya was driven by the convergence of political, technical, and public needs. While counties have developed their own facility autonomy laws to fit local contexts, some provisions are not fully aligned with the national legislation. Some aspects of both the county specific and national laws are not implemented. These include allocation of matching funds from the exchequer and reimbursing facilities for expenses incurred from providing care to indigents and for unpaid bills. The implementation of autonomy also varies, with some aspects partially or not implemented. Autonomy reforms have contributed to improved decision-making, staff satisfaction, availability of essential medicines, and facility maintenance. However, challenges have emerged, including the failure of counties to provide matching funds, which disproportionately affects lower-level facilities that do not generate revenue. Additionally, the absence of waiver repayment mechanisms has led to inequities, and the risk of increased service costs threatens financial accessibility for marginalized populations. Conclusion Facility autonomy reforms support people-centered decision-making and aligns with PHC principles. While these reforms hold promise for improving service delivery and access, their success depends on complementary measures such as sustainable funding mechanisms and stronger protections for vulnerable populations.

Medical oxygen is an essential medicine that is often unavailable for patients when they need it. We explored if ‘Outsourced Oxygen to the Bedside’ (O2B) pilots, where private providers deliver a package of services, were successful in ensuring reliable oxygen access at the patient bedside. We conducted a sequential explanatory mixed-methods assessment of O2B pilots in Kenya, Nigeria, India, Tanzania, and Uganda from September 2024 – January 2025. A quantitative cross-sectional facility audit described facility contexts, tested equipment functionality and assessed healthcare worker (HCW) oxygen knowledge. Qualitative interviews with HCWs and managers explored experiences of O2B pilots. We studied 28 of the 80 facilities participating in the pilots, 179 HCWs completed the knowledge survey, and 59 qualitative interviews were conducted. In the audit, we found O2B provided oxygen equipment more functional and usable than non-O2B equipment: 49.0% vs 30.1% (p-value<0.001) for cylinders, 82.9% vs 20.3% (p-value<0.001) for concentrators, and 84.0% vs 70.0% (p-value=0.172) for pulse oximeters. Overall, 21.8% (39/179) of HCWs had received training from O2B providers, and their oxygen knowledge was slightly higher than those who had not (mean score 15.3/24 vs 13.9/24, p-value=0.002). Qualitative interviews highlighted positive changes in oxygen access and the ability to treat patients, but also mixed understandings of the O2B services being provided, and requests for additional services. O2B pilots appear to improve medical oxygen access, with effective maintenance and repair services being a key mechanism. However, tailoring to local needs and remaining gaps in HCW capacity need to be addressed.

Abstract Background Knowledge translation (KT) is regarded as important for supporting evidence-informed health policy-making. While KT models have moved beyond linear understandings of the evidence–policy relationship, they continue to underplay the politics that shape how evidence is produced, framed, interpreted, negotiated and used during policy-making. As a result, KT strategies are often designed for policy processes that bear little resemblance to real-life policy-making. Methods This study argues for a reframing of KT for policy as an embedded and politically situated process. To inform this reframing, we examined how KT happens during health policy-making in Kenya. We examined who engages in KT, how they do it, in which spaces and the outcomes of these practices. Data were collected through in-depth interviews with a range of policy actors (n = 35), nonparticipant observations (52 h) and document reviews (n = 34). Data analysis was informed by the study’s conceptual framework. Results The findings show that KT was enacted by a range of actors, including policy-makers themselves. These actors practised both so-called structured and fluid forms of KT and mobilized evidence to inform, advocate, justify or contest policy positions. In addition, KT happened in both formal and informal spaces. Strategic framing of evidence and other relational activities were central to mobilizing evidence. The outcomes of these practices were often relational and incremental. Importantly, context constituted KT by shaping what counts as evidence, whose voices were influential, and where action was possible. Conclusions This study offers a practise-based understanding of KT by reframing it as a contextually-constituted, situated practice that requires adaptive system-oriented approaches.

Introduction Moral distress is the psychological discomfort experienced by healthcare providers when prevented from acting on their ethical values. Although extensively studied in high-income settings, it remains relatively unexplored in Africa, where chronic resource limitations and systemic constraints shape clinical practice. This scoping review mapped African literature examining how moral distress is conceptualised and discussed, its drivers and interventions implemented to address it with a particular focus on the balance between individual and organisational perspectives. Methods A systematic search of databases identified papers on moral distress and related concepts among healthcare providers in Africa. Data extracted included: publication year, geographical focus, study design, participants, healthcare setting, conceptual framing, definitions, factors contributing to moral distress and descriptions of interventions and their evaluations. The results were analysed thematically considering individual and organisational perspectives. Results 30 papers published between 1999 and 2025 across 11 African countries were included. Of these, 14 were qualitative, 10 quantitative, 2 mixed methods, 1 review, 2 commentaries and 1 book chapter. Moral distress was commonly framed as an individual psychological burden, yet its primary drivers were identified as organisational including staff shortages, excessive workloads, inadequate resources and limited institutional support. Quantitative papers explicitly referred to ‘moral distress’, while qualitative papers generally described ethical and moral challenges more widely. Reported interventions were mainly proposed: counselling, debriefing, ethics committees and better staffing were recommended but rarely implemented or evaluated. In practice, healthcare workers relied on informal coping strategies such as peer support, prayer and improvisation. Conclusion Moral distress is increasingly explored in the literature on African health systems but remains inconsistently defined and inadequately addressed at the organisational level. Despite widespread acknowledgement of its organisational and systemic origins, responsibility for managing its effects falls largely on individuals. This review supports a systems-level understanding of moral distress and highlights the need for organisational and policy change processes. Future research should move beyond description to identifying and evaluating team-based and organisational strategies that effectively reduce or manage moral distress.

Community pharmacies are increasingly recognized as access points for public health interventions (PHIs) such as vaccination, family planning services, and disease screening. In Kenya, evidence suggests the feasibility of pharmacy-delivered PHIs; however, the uptake remains inconsistent. This is partly attributed to poor programme design without taking pharmacy providers preferences into consideration. We employed a discrete choice experiment (DCE) to investigate community pharmacists' preferences for attributes of PHIs delivered in community pharmacies in Kenya. We constructed a Bayesian efficient design and conducted a DCE survey among 663 community pharmacy providers in Makueni, Nairobi, and Kisumu counties in Kenya from January 2025 to March 2025. Panel multinomial mixed logit, generalized multinomial logit, and latent class models were used in the analysis. We also estimated willingness to pay (WTP) and willingness to accept (WTA) estimates using cost and profit margins as the monetary estimates, respectively. We found that community pharmacists were willing to offer PHIs with a low preference for opting out (β = -3.5723, P < 0.01). Preferences for PHIs significantly increased with higher profit margins (β = 0.028, P < 0.01) and decreased with higher cost of equipment (β = -0.00023, P < 0.01). There were higher preferences for PHIs that require moderate training (β = 0.266, P < 0.01) and extensive training (β = 0.141, P < 0.05) compared to no additional training and lower preferences for PHIs with complex interventions compared to simple interventions (β = -0.323, P < 0.01). The WTP estimates showed that providers were willing to pay Khs. 11 738 (USD 90) for moderate training and Kshs. 7327 (USD 56) for extensive training. Moreover, the WTA estimates showed that providers were willing to accept a 10.9% increase in profit margin in order to deliver complex interventions. In addition to this, a three-class latent class model revealed preference heterogeneity among the respondents. These findings can be used to inform the design of PHIs to enhance uptake and acceptability among providers.

The maternal and newborn health (MNH) service delivery redesign (SDR) in Kakamega County, Kenya, represents the country's first system-level reorganization of MNH services. The reform aimed to improve care quality and reduce mortality by centralizing delivery services at designated hubs. Using a political economy lens, we examined how ideology, political dynamics, and institutional structures shaped the agenda-setting, adoption, implementation, and sustainability of SDR. We drew on data from document reviews, stakeholder analysis, semi-structured interviews, and non-participant observation to assess the structural, contextual, and institutional factors influencing the reform. Ambiguity around SDR's purpose contributed to the community's uncertain engagement characterized by neither full endorsement nor resistance, highlighting the need for clearer communication and participation to build ownership. The interaction between formal institutions (county health governance and partnership frameworks) and informal norms (trust, shared interpretation, and relational coordination) created early momentum for implementation, particularly among health system actors. However, limited financial capacity and unclear alignment with national policy priorities undermined progress and long-term viability. Kakamega's experience demonstrates how political incentives, devolved autonomy, and local institutional context jointly shape reform outcomes. Achieving successful implementation of system-level reforms requires integrating local political leadership, strengthening community engagement, aligning with evolving national policies, and securing predictable financing. This study provides practical lessons for future MNH and system-level reforms in Kenya and similar decentralized, resource-constrained settings. Lessons include the importance of balancing formal and informal institutions to ensure both political feasibility and enduring impact.

Introduction: Access to medical oxygen remains a challenge, with 60% of the worlds population lacking access to quality oxygen services. We explored whether "outsourced oxygen to the bedside" (O2B), where private providers offer bundles of oxygen services, could be adopted and scaled across diverse health systems, to improve patient access to oxygen. Methods: Qualitative interviews were conducted with healthcare workers (HCWs), facility management staff and district medical officers in India, Nigeria, Tanzania, Kenya and Uganda, who had taken part in an O2B pilot. Interviews were conducted between 19th November 2024 and 25th January 2025, and explored the feasibility, fidelity, acceptability, perceived benefits and weaknesses of five O2B models. Analysis used a pragmatic codebook approach, with inductive and deductive coding, informed by implementation science frameworks. Results We conducted 59 interviews, with managers and HCWs from 20 health facilities. We identified five themes relating to the potential for O2B pilots to be adopted within the health system: effect on oxygen culture, feasibility of whole of facility solutions, promotion of local ownership, being willing but unsure about the ability to pay, and the desire for hybrid tailored service models. HCWs and facility staff raised several positive factors within these themes but highlighted that understanding local facility needs and tailoring the services to embed within existing structures were important for sustainability. Conclusion Overall, the O2B service approach shows potential for implementation beyond the pilots, but more understanding of how to optimize service delivery packages to different facility needs, while also prioritizing affordability is needed. ### Competing Interest Statement TB declares technical consultancies with UNICEF, the World Bank, USAID, and PATH, and is Board member of the non-profit organisation EECC Global, all outside the submitted work. HG has provided unpaid technical advice on oxygen therapy to FREO2 Foundation (one of the O2B providers). ### Funding Statement The research was funded by Brink through a grant from the UK FCDO. The views expressed in this report are those of the authors. This material has been funded by UK International Development as a part of the Oxygen CoLab; however, the views expressed do not necessarily reflect the UK governments official policies, nor those of any of the individuals and organisations referred to in the report. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approvals were obtained from ethical review boards in each country: Monk Prayogshala Institutional Review Board, India (reference: #156-024); Maseno University Scientific and Ethics Review Committee, Kenya (reference: MSU/DRPI/MUSERC/01361/23); National Commission for Science, Technology and Innovation, National Commission for Science, Technology and Innovation, Kenya (license number: NACOSTI/P/24/37427, reference: #673262); Health Research and Ethics Committee, LASUTH, Lagos State, Nigeria (reference: LREC/06/10/2498); Health Research Ethics Committee, Ogun State, Nigeria (reference: OGHREC/467/2024/290/APP); National Institute for Medical Research, Tanzania (reference: NIMR/HQ/R.8a/Vol.IX/4743); Ugandan National Council for Science and Technology, Uganda (reference: HS5437ES); Makerere University School of Health Sciences REC, Uganda(reference: MAKSHSREC-2023-600). Approval was granted by the Swedish Ethics Review Authority for the processing of personal data (reference: DNR 2024-00868-01). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Given the qualitative nature of the data, transcripts cannot be sufficiently anonymised for Open Data Access. Data can be requested for the purposes of further academic research, by contacting Carina King (carina.king{at}ki.se) and Freddy Eric Kitutu (kitutufred{at}gmail.com). Requests will be reviewed and discussed with the site qualitative leads, and approval from local ethical committees will need to be sought.

Efforts to strengthen knowledge translation (KT) for policy-making often call for greater engagement with the policy process and its actors. Yet, existing KT approaches often focus on communication and dissemination of evidence and undertheorise the role and influence of policy actors on KT. As such, this study examines how, why, and to what effect policy actors shape KT. Our findings address a critical gap in the KT literature regarding the relational dimensions of KT for policy-making in low-middle-income countries. We utilised purposive and snowball sampling to identify participants who are involved in health policy-making and KT in Kenya. This included policy-makers, academics/researchers, knowledge intermediaries, and external partners (development and implementation partners). Data were collected through in-depth interviews (n = 32), observations (n = 52 h), and document reviews (n = 34). Data analysis was informed by a theoretical framework that combined perspectives from actor-centred institutionalism, Gaventa's PowerCube, boundary work, and coproduction. Our findings reveal how actor influence in KT is shaped by institutional mandates and roles, which, in turn, shape how actors perceive their position and authority in KT processes. While some actors viewed themselves as constrained to the role of evidence provision, others acted as boundary spanners across policy spaces, enabled by their institutional flexibility and financial resources. In addition, actor interests shaped when and how they exercised power to support or resist KT. Furthermore, access to policy spaces determined whose evidence was visible and perceived as legitimate, reflecting deeper power structures. These dynamics frame KT as a relational process mediated by political and institutional structures. As such, this study highlights the need to reconceptualise KT to integrate relational and structural dimensions, moving beyond evidence dissemination to addressing actor and power dynamics. It contributes novel insights into the interplay between actors, context, and power in shaping KT outcomes.

The capacity of health systems to provide quality care for pregnant adolescents remains underexplored. This study examined the quality of care and adverse delivery outcomes (mistreatment and obstetric complications) among pregnant adolescents in Ethiopia, Kenya, and South Africa using data from the MNH eCohort longitudinal survey. This study followed 3,051 pregnant women from their first antenatal care (ANC) visit to postpartum period. We used descriptive analysis to compare outcomes between adolescents (<20) and adults (20+), and logistic regression to identify factors associated with mistreatment and adverse delivery outcomes among adolescents. A total of 380 adolescents (mean age 18) and 2,671 adults (mean age 28) were included in the analysis. Adolescents were more likely to be unmarried (63%), particularly in Kenya (53%) and South Africa (99%), while most in Ethiopia were married (95%). Education level varied, with many Ethiopian adolescents lacking formal education. Only 23% of adolescents attended their first ANC visit in the first trimester compared to 30% of adults (p=0.003), with lower follow-up testing and adherence to iron and folic acid supplementation. The mean ANC visits was 3.8, with higher levels among adults in Ethiopia and Kenya. Over 95% of women delivered in health facilities, but consent for vaginal examinations was low (46%). Mistreatment was reported by 20% of women, with higher rates among adolescents (27% vs. 19%, p=0.003). A higher risk of obstetric complications was associated with rural residence (OR: 2.25, 95% CI: 1.09–4.63) and antenatal depression (OR: 2.43, 95% CI: 1.19–5.00). Mistreatment was associated with rural residence, public facility visits, and experiencing intimate partner violence. Kenyan adolescents, privacy during delivery, and high quality of care rating care were protective factors for mistreatment. Adolescents face critical gaps in maternal healthcare, requiring strengthened adolescent-friendly services, rural healthcare investments, and respectful maternity care policies to improve outcomes. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement MEK received funding for the QuEST network and the eCohort study. Funding was provided by the Bill and Melinda Gates Foundation (grant number INV-005254) and the Swiss Federal Department of Foreign Affairs (grant number 81067262). The funders did not play any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study protocol was reviewed and approved by the Institutional Review Boards (IRB) of the Harvard T.H. Chan School of Public Health (protocol #IRB22-0487), the Kenya Medical Research Institute (protocol number KEMRI/SERU/CGMR-C/4226), the Ethiopian Public Health Institute (protocol number EPHI-IRB-448-2022) and the University of KwaZulu-Natal (protocol number BREC/00004645/2022). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data used in this study data can be made available through a formal process of request to the KEMRI Institutional Data Access/Ethics Committee. The details of the guidelines can be found on the KEMRI Wellcome website (https://dataverse.harvard.edu/dataverse/kwtrp). Access to data can be provided via the KEMRI Wellcome Data Governance Committee: dgc{at}kemri-wellcome.org.

Civil society actors are widely recognized for advocating the public interest in health policy. However, their role in contributing different types of evidence to inform policy is less explored. To explore this topic, members of the Healthcare Information for All (HIFA) online forum and the Supporting Inclusive and Accountable Health Systems Decisions for Universal Health Coverage (SUPPORT-SYSTEMS) research project conducted a four-week online discussion. The discussion focused on defining civil society, its role in health policy, the types of evidence it provides, and how this evidence is used and valued. Weekly focal questions encouraged HIFA members to share experiences of civil society engagement and the use of evidence in health policy-making. The thematic analysis identified four key messages. First, defining civil society requires critical reflection, as actors differ significantly in their interests, political ties, and influence. These distinctions affect how representative their evidence is and whether it reflects vested interests. Second, policy-making structures can support meaningful civil society participation, thereby strengthening the use of evidence and the legitimacy of policy decisions. Third, civil society provides valuable local and tacit knowledge that complements scientific evidence, though safeguards are needed to prevent bias or misrepresentation. Fourth, political economy factors-such as power imbalances, gatekeeping, and funding constraints-shape the influence of civil society evidence on policy. Overall, the discussion highlighted the diverse roles civil society can play in health policy and the importance of institutional mechanisms to support responsible evidence use. Thematic discussions in communities of practice (CoPs) like HIFA offer a dynamic and inclusive approach to engaging stakeholder knowledge in research projects.

BACKGROUND:The importance of developing and supporting emotional well-being among all frontline health system staff, including those in leadership positions, is increasingly recognized as essential to health system resilience and patient outcomes. Nurses working in many public sector newborn units in sub-Saharan Africa work in highly stressful environments; often asked to perform what has been described as 'an impossible task' of meeting international standards of nursing in significantly under-resourced environments. This paper focuses on the emotional dimensions of nurses' daily work in newborn units in Kenya. These dimensions of newborn nurses' work are rarely documented and are under-supported in policy and practice. METHODS:We conducted an empirical qualitative study design in two public hospital newborn units in Kenya. Methods included observations of nurses in their workplaces, individual in-depth interviews with 21 health workers (mostly nurses), and reviews of self-administered questionnaires submitted to us by these staff. Data were analyzed using a thematic analysis approach. RESULTS:Neonatal nurses reported emotions ranging from pride and satisfaction to devastation, heartache, and indifference, with handling infant deaths and communicating bad news to families particularly distressing. Influenced by individual, interpersonal, and structural factors, emotions play a central role in nurses' interactions with their peers, supervisors, ward-in charges, and parents. Interactions with supervisors and in-charges have a an especially powerful impact on staff emotional well-being and team cohesion, and informal support from peers is a key coping strategy. CONCLUSION:We draw on our data, the wider literature, and nurses' recommendations to reflect on the interplay between emotional well-being and ethical nursing practice, and to make suggestions for ongoing health system strengthening efforts.

Background:Health systems in low-and middle-income countries (LMICs) face chronic Human Resources for Health (HRH) shortages. This is especially worse in rural and primary healthcare settings. The Cuban government since 1960s has been implementing a policy strategy for producing healthcare workers for export, to boost their economy, support humanitarian efforts and boost their global diplomatic influence. Several LMICs have since established health cooperation programs with Cuba to import health workers to address their shortages. This review aimed to examine the emergence, design, utility, outcomes, and lessons learned from the implementation of these programs. Methods:We conducted a scoping review using the Joanna Briggs Institute (JBI) methodology and searched for literature across four databases. Two independent reviewers screened and selected relevant articles based on pre-defined criteria. We extracted data and synthesized findings using thematic analysis. Results:We included 71 articles after screening 3509 articles. Cuban health cooperation programs have been implemented in many LMICs in South America, Africa, Southeast Asia, and the Pacific region. These programs are formalized primarily through bilateral agreements and implemented as exchange initiatives. This involves importing Cuban healthcare workers and sending collaborating country students to study in Cuba. These programs aimed to address HRH shortages, maldistribution, inadequate training capacity, and respond to medical emergencies in the host countries. Cuban healthcare workers, primarily family physicians, within the host countries; are deployed in primary healthcare settings, increasing the rural health workforce, and improving healthcare access and outcomes. Challenges included opposition from local medical professionals, underutilization due to poorly coordinated recruitment, and language barrier in non-Spanish speaking countries. Conclusion:Cuban health cooperations in LMICs have shown diverse results based on their structures. Long-term comprehensive programs have proven to be more successful in boosting the healthcare workforce and enhancing health outcomes. Key factors for optimizing HRH health cooperation include effective collaborative decision-making and need-based deployment in alignment with national health system goals.

Background Kenya has identified Primary Health Care Networks (PCNs) as a key reform to strengthen Primary Health Care (PHC) delivery and enacted the Primary Health Care Act of 2023 to support their implementation. PCNs were piloted in Kisumu and Garissa counties in 2020 and rolled out nationally in 2023. However, little is known about how PCNs are being implemented across diverse county contexts. This study examined the emergence and implementation experience of the PCN reform in Kenya. Methods We used a cross-sectional qualitative process evaluation design. We collected data at the national level and in five purposefully selected counties, using in-depth interviews (n = 65) and document reviews, between February and June 2024. Participants included stakeholders from the national level (Ministry of Health, development and implementing partners, and the Council of Governors), county level (county health departments, sub-county managers, multi-disciplinary team (MDT) members, facility managers, and frontline health workers), and community level (community health committee chairs and community health workers). We reviewed policy documents and county reports on PCN implementation for document review. We analysed the data using a thematic approach. Results The emergence of PCNs as a policy reform was motivated by a technocratic process that identified underlying challenges in PHC service delivery and proposed PCNs as a solution, as well as political interest and support that facilitated their adoption. The implementation effectiveness of PCNs varied across the study counties, with critical aspects of PCN design, such as the establishment of MDTs and the digitisation of PCNs, being inadequately implemented. The effectiveness of PCNs' implementation may have been constrained by capacity gaps in key foundational aspects of PHC health systems, including financing, human resources, health commodities, and information systems. Moreover, the implementation effectiveness of PCNs may have been undermined by the limited integration of key health facility functions, including financing, human resource management, health commodity supply chains, information systems, and care coordination. Conclusion Strengthening PCN implementation in Kenya requires investment in policy capacity to ensure effective implementation. The foundational aspects of PHC systems must be reinforced. The PCN design should be refined to enhance the integration and coordination of key health facility functions.

Background Health systems in low-and middle-income countries (LMICs) face chronic Human Resources for Health (HRH) shortages. This is especially worse in rural and primary healthcare settings. The Cuban government since 1960s has been implementing a policy strategy for producing healthcare workers for export, to boost their economy, support humanitarian efforts and boost their global diplomatic influence. Several LMICs have since established health cooperation programs with Cuba to import health workers to address their shortages. This review aimed to examine the emergence, design, utility, outcomes, and lessons learned from the implementation of these programs. Methods We conducted a scoping review using the Joanna Briggs Institute (JBI) methodology and searched for literature across four databases. Two independent reviewers screened and selected relevant articles based on pre-defined criteria. We extracted data and synthesized findings using thematic analysis. Results We included 71 articles after screening 3509 articles. Cuban health cooperation programs have been implemented in many LMICs in South America, Africa, Southeast Asia, and the Pacific region. These programs are formalized primarily through bilateral agreements and implemented as exchange initiatives. This involves importing Cuban healthcare workers and sending collaborating country students to study in Cuba. These programs aimed to address HRH shortages, maldistribution, inadequate training capacity, and respond to medical emergencies in the host countries. Cuban healthcare workers, primarily family physicians, within the host countries; are deployed in primary healthcare settings, increasing the rural health workforce, and improving healthcare access and outcomes. Challenges included opposition from local medical professionals, underutilization due to poorly coordinated recruitment, and language barrier in non-Spanish speaking countries. Conclusion Cuban health cooperations in LMICs have shown diverse results based on their structures. Long-term comprehensive programs have proven to be more successful in boosting the healthcare workforce and enhancing health outcomes. Key factors for optimizing HRH health cooperation include effective collaborative decision-making and need-based deployment in alignment with national health system goals.

How health facilities are managed determines their performance and health service delivery. Management capacity of health facilities comprises the competency of managers at the individual level and the management support and work environment in their institutions. Evidence shows this management capacity influences service delivery and performance of the facility. For LMICs, there are evidence gaps as existing evidence is scarce, varied in the assessment of management capacity of PHC facilities and report a measurement gap due to the scarcity of assessment tools contextualised to the LMIC PHC setting. Our review aims to address these gaps by mapping and summarising the existing literature on management capacity of PHC facilities in LMICs, its components and performance across these components, providing evidence on what needs to be improved for better service delivery. We used Arksey and O`Malley`s scoping review methodology. We searched PubMed, Scopus, Web of Science and Google Scholar and hand-checked reference lists. We synthesized findings using a thematic approach. We included 21 articles out of the 3867 articles gotten. Individual capacity consisted of managerial competencies grouped into seven groups: (1) communication and information management, (2) financial management and planning, (3) human resource, supportive and performance management, (4) community stakeholder and engagement, (5) target setting and problem solving, (6) leadership and (7) situational analysis. Institutional capacity included functional support systems grouped into; (1) availability of resources, (2) support to undertake duties and (3) clear roles and responsibilities. Gaps were prevalent across individual and institutional capacities. There were deficiencies in the managerial competencies of the managers and the functional support systems were not adequate. These negatively affected facility service delivery and performance. There is still a scarcity of studies hence more research is needed. Furthermore, interventions such as training and supportive supervision should be considered in improving the managerial competencies of managers.

This research applies the Cumulative Complexity model to examine patient experiences of hypertension management following prescription of anti-hypertensive medication in the public health system in Kenya. Set in Kiambu County, central Kenya, it draws on abductive analysis of interviews with patients (n = 24), caregivers (n = 7) and non-participant observation in four purposively selected public facilities conducted between November 2022 and April 2023. Patients undertook three kinds of ‘work’ to reduce their blood pressure: processing work to accept hypertension diagnosis and its chronic dimension; practical work managing care and medications, and work of managing emotions. Four inter-related domains of patient capacity influenced patients' ability to do this work: individual financial resources; physical functioning; social support and religious faith. Variations in treatment cost and medicine availability increased patient workload. When workload overwhelmed capacity treatment adherence was interrupted. Interruptions in treatment resulted in negative feedback loops further reducing patient capacity. Recognising temporal variability in workload and capacity is key to understand treatment adherence in resource constrained settings. Consideration of adaptive counter-agency can strengthen treatment burden models. We encourage policy makers to prioritise addressing treatment burdens to support treatment adherence and sustained hypertension control.

BackgroundPrimary care networks (PCNs) are increasingly being adopted in low- and middle-income countries (LMICs) to improve the delivery of primary health care (PHC). Kenya has identified PCNs as a key reform to strengthen PHC delivery and has passed a law to guide its implementation. PCNs were piloted in two counties in Kenya in 2020 and implemented nationally in October 2023. This protocol outlines methods for a study that examines the impact, implementation experience and political economy of the PCN reform in Kenya.MethodsWe will adopt the parallel databases variant of convergent mixed methods study design to concurrently but separately collect quantitative and qualitative data. The two strands will be mixed during data collection to refine questions, with findings triangulated during analysis and interpretation to provide a comprehensive understanding of PCN implementation. The quantitative study will use a controlled before and after study design and collect data using health facility and client exit surveys. The primary outcome measure will be the service delivery readiness of PHC facilities. We will use a random sample of 228 health facilities and 2560 clients in four currently implementing PCNs, four planning to implement and four control counties at baseline and post-implementation. We shall undertake a preliminary cross-sectional analysis of the data at baseline from October to December 2023, followed by a difference-in-difference analysis at the endline from October to December 2024 to compare the outcome differences between the intervention and control counties over a 12-month period. The qualitative study will include a cross-sectional process evaluation and political economy analysis (PEA) using document reviews and approximately 80 in-depth interviews with national and sub-national stakeholders. The process evaluation will assess the emergence of PCN reforms, the implementation experience, the mechanism of impact and how the context affects implementation and outcomes. The PEA will examine the interaction of structural factors, institutions and actors/stakeholders' interests and power relations in implementing PCNs. We will also examine the gendered effects of the PCNs, including power relations and norms, and their implications on PHC from the supply and demand sides. We shall undertake a thematic analysis of the qualitative data.DiscussionThis evaluation will contribute robust evidence on the impact, implementation experience, political economy and gendered implications of PCNs in a LMIC setting, as well as guide the refining of PCN implementation in Kenya and other LMICs implementing or planning to implement PCNs to enhance their effectiveness.