Abstract:
Background: 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 contribution of changing risk factors and intervention
coverage on the sub-national changes in U5M remains poorly defined.
Methods: Sub-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.
Results: Nationally, 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.
Conclusion: Contributions 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