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Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015
  1. Emily C Keats1,
  2. William Macharia2,
  3. Neha S Singh3,
  4. Nadia Akseer1,4,
  5. Nirmala Ravishankar5,
  6. Anthony K Ngugi2,
  7. Arjumand Rizvi6,
  8. Emma Nelima Khaemba7,
  9. John Tole2,
  10. Zulfiqar A Bhutta1,6,2,4
  1. 1 Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
  2. 2 Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
  3. 3 Centre for Maternal, Adolescent, Reproductive, and Child Health, London School of Hygiene & Tropical Medicine, London, UK
  4. 4 Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
  5. 5 Independent consultant, Nairobi, Kenya
  6. 6 Division of Woman and Child Health, Aga Khan University, Karachi, Pakistan
  7. 7 African Population and Health Research Center, Nairobi, Kenya
  1. Correspondence to Dr Zulfiqar A Bhutta; Zulfiqar.bhutta{at}


Introduction Despite recent gains, Kenya did not achieve its Millennium Development Goal (MDG) target for reducing under-five mortality. To accelerate progress to 2030, we must understand what impacted mortality throughout the MDG period.

Methods Trends in the under-five mortality rate (U5MR) were analysed using data from nationally representative Demographic and Health Surveys (1989–2014). Comprehensive, mixed-methods analyses of health policies and systems, workforce and health financing were conducted using relevant surveys, government documents and key informant interviews with country experts. A hierarchical multivariable linear regression analysis was undertaken to better understand the proximal determinants of change in U5MR over the MDG period.

Results U5MR declined by 50% from 1993 to 2014. However, mortality increased between 1990 and 2000, following the introduction of facility user fees and declining coverage of essential interventions. The MDGs, together with Kenya’s political changes in 2003, ushered in a new era of policymaking with a strong focus on children under 5 years of age. External aid for child health quadrupled from 40 million in 2002 to 180 million in 2012, contributing to the dramatic improvement in U5MR throughout the latter half of the MDG period. Our multivariable analysis explained 44% of the decline in U5MR from 2003 to 2014, highlighting maternal literacy, household wealth, sexual and reproductive health and maternal and infant nutrition as important contributing factors. Children living in Nairobi had higher odds of child mortality relative to children living in other regions of Kenya.

Conclusions To attain the Sustainable Development Goal targets for child health, Kenya must uphold its current momentum. For equitable access to health services, user fees must not be reintroduced in public facilities. Support for maternal nutrition and reproductive health should be prioritised, and Kenya should acknowledge its changing demographics in order to effectively manage the escalating burden of poor health among the urban poor.

  • child health
  • health policy
  • health systems
  • nutrition
  • maternal health

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  • Handling editor Sanni Yaya

  • Contributors ZAB and WM conceptualised the study and wrote the proposals for funding. AKN led the mortality analysis. NSS led the HSP component, with inputs from JT and ECK. NR led the health financing domain. NA designed and conducted the multivariable analyses, with support from AR, ECK, ENK and ZAB. NSS, NR and NA drafted their respective sections within the results. ECK drafted the full manuscript, with inputs from AKN, WM, NA, NSS and ZAB. All authors reviewed and agreed to the analyses, results interpretation and write up of the final draft. ZAB is the guarantor.

  • Funding Countdown to 2015 Initiative supported by US Fund for UNICEF with funding from the Bill and Melinda Gates Foundation (grant number: OPP1058954).

  • Disclaimer The funders of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval The institutions that commissioned, funded or administered the surveys were responsible for all ethical procedures.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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