Landscape analysis of the Kenyan policy on the treatment and prevention of diarrheal disease among under-5 children

Lack of focus on zoonotic pathways to diarrhoea infection

Although the use of the policy guidelines has been identified as effective in addressing diarrhoea infection over time, they lack focus on some key pathways to infection, for example, the man-animal-environmental interaction, which researchers suggest is critical in effectively addressing the needs of LMICs and communities.41 This is important, following the growth of slum environments and the increasing uncontrolled human-animal interactions that could be associated with health risks. Previous research has established linkages between human diarrheal infections and domestic animal husbandry.5 42 A systematic review and meta-analysis found consistent evidence of a positive association between exposure to domestic food-producing animals and diarrheal illness across a range of animal exposures and enteric pathogens.42 Out of 29 studies included in their review, 20 (69.0%) reported a positive association between domestic animal exposure and diarrhoea, with domestic exposure to poultry revealing a substantial association with human campylobacteriosis. It was concluded that exposure to domestic animals should be considered a risk factor for human diarrheal illness and recommended additional studies to identify potential mitigation strategies to address the risk.42

Similarly, Penakalapati and colleagues’ 2017 study underscored how humans can be exposed to pathogens from poorly managed animal faeces, particularly in communities where animals live in close proximity to humans via water, sanitation and hygiene-related pathways and where household livestock, small-scale animal operations and free-roaming animals are common.5 Exposure to animal faeces was linked to diarrhoea, soil-transmitted helminth infection, trachoma, environmental enteric dysfunction and growth faltering. The authors postulated that interventions such as reducing cohabitation with animals, provision of animal faeces scoops, controlling animal movement, creating safe child spaces, improving veterinary care, and hygiene promotion are important in breaking the barrier in infections.5 These interventions, though not new, are largely lacking in current policy guidelines, frameworks and action plans. The proposed future research agenda included evaluating behaviours related to contact with animal faeces; animal faecal contamination of food; cultural behaviours of animal faecal management; acute and chronic health risks associated with exposure to animal faeces and factors influencing concentrations and shedding rates of pathogens originating from animal faeces.5 This elaborate research agenda highlights the gaps in policy and practice in diarrhoea management and prevention in Kenya and reiterates the evidence that zoonotic pathways contribute to diarrheal infections. This is largely not emphasised and operationalised in the current policies and guidelines for the management and prevention of under-5 diarrhoea in Kenya.

Environment-pathogen linkages

Measuring the complexities of pathogens in the environment is essential for understanding transmission dynamics across human populations. Evidence from urban Kenya and Haiti revealed that young children, including infants, ingest high doses of a wide array of enteric pathogens from exposure to soil, surface water and objects during play in community areas.3 4 43 44 Furthermore, increased spatial movement of children around the community increases the probability of ingesting new types of pathogen species.35 These different environmental diarrhoea transmission pathways have been historically and clearly illustrated in LMICs22 but remain generally absent in current policy and intervention guidelines in Kenya.

Similar to vaccine interventions, a certain threshold of household and community-level sanitary conditions is suggested to be required for the evolution of a population from multipathogen, high-prevalence disease burden to rare pathogen-specific disease outbreaks.45 A combination of societal development improvements that may be required to achieve multipathogen herd immunity was identified, which include shifts at the point of faeces generation such as latrines and sewers or animal management and shifts in basic household or neighbourhood conditions such as concrete floors or increased wastewater drainage. The current diarrhoea management policy frameworks and guidelines for management of child diarrhoea for Kenya is lacking emphasis in these environment-pathogen prevention pathways.

Limited focus on rapid diagnosis, vaccine development and deployment

Whereas the policy was projected to lead to rapid management, treatment, prevention and control of diarrheal diseases, it remains limited in offering rapid diagnosis, especially as a fair proportion of diarrheal pathogens are difficult-to-culture and yet-to-be-identified.46 Out of the five pathogens that predominate low-income settings: Cryptosporidium, Shigella, non-typhoidal Salmonella and enterotoxigenic Escherichia coli, vaccines are only currently available against rotavirus, whose rollout also remains limited and concentrated among upper-middle-income or high-income countries.17 The Kenyan policy recognises rotavirus but did not seem to anticipate the challenges of its availability and modalities for its delivery to under-5 children across the country. Moreover, the development of vaccines beyond rotavirus is not captured.

Limited focus on demographic and social determinants of health

The 2014 policy elaborates on home and health facility management, though weak on how to operationalise the social determinants of health. Studies in Kenya and elsewhere have shown that ages of life may fairly protect infants against bacterial infections, as the host immunity heightens with advances in age.47 48 Related to the age of the child is the timing of complementary feeding which may result in frequent bacterial infections causing diarrhoea, with introducing food at 6 months linked to elevated probable bacterial infections.48 An important demographic factor in the literature is gender. Female participants (between 6 months and 36 months in Kenya and <5 years in rural Sudan) were found in some studies to be nearly twice more likely to be infected with enteric pathogenic bacteria than their male counterparts, which may be attributed to the differences in their immune systems and other physiological factors.47–49 The focus on sociodemographic factors is lacking but needs to be accounted for in both policy and action around diarrhoea infection prevention and management moving forward.

Weak funding commitment and unclear pathways

The 2014 policy guidelines gave a clear recognition that adequate resources will be needed to implement its provisions. However, it only encompassed a statement of advocacy without defined funding targets and specific funding responsibilities. The policy called for advocacy for appropriate financial mobilisation by all partners in healthcare provision: medical training institutions, faith-based organisations, the pharmaceutical industry, development partners and the community.13 Further, it envisaged that resource allocation for child health programmes will be increased so that the strategies outlined in the policy can be achieved. The strategies targeted for implementation are capacity building, strengthening health systems and empowering families and communities to take charge in the prevention and management of diarrheal diseases. Successful implementation of the policy was anchored on the coordinated action of many sectors and the participation of all stakeholders in the health sector. Despite this articulation, the pathways to financing the implementation of the policy were not clearly identified. Advocacy was adopted as a key approach to mobilise resources and enhance partnerships with political and social leadership in order to build support and commitment for diarrhoea management and prevention. Notwithstanding, the costing and funding targets were lacking in the policy and the pathways for resource mobilisation and enhanced partnerships were not identified.

Monitoring and evaluation indicators lacking contextual nuances

Monitoring and evaluation were identified as crucial pathways to implementation success, as well as appropriate indicators to be monitored, including caseload, degree of dehydration and treatment. However, risk factors for diarrhoea vary geographically and spatially, and determining Kenya’s in-country diarrheal prevalence and its associated risk factors will be needed to provide a basis for focused interventions by local implementing agencies and enable equitable resource allocations in public health.50 While national indicators may be generally available, they blur intersubgroup and intrasubgroup inequities and often lack aggregation at local levels, especially among marginalised groups as slum dwellers in urban informal settlements, where the needs are located and where progress needs to be measured and priorities deciphered.51

Study limitations

Our analysis was based on a document review of the existing policies and extant literature, so we were not in a position to identify some of the processes implemented in practice that can affect enteric infection policies, management and prevention outcomes. Critical evaluation of real interventions and their appropriateness for target audiences may be as important as policy options and associated campaigns themselves and necessary to establish the effectiveness of current interventions. Critical questions on what has been achieved? What gaps need to be addressed? And what levels of investment are still needed at different health facility and community levels? will need answers moving forward.52 Therefore, future research agenda will need to include how the policies are implemented in practice and across subgroups, communities and regions. This will enable an evaluation of where and how the policy meets the people and where participatory approaches and collaboration mechanisms will be developed. Further interrogation of the actors that participated in policy formulation and implementation strategies will need to be engaged in relation to health system preparedness in incorporating research evidence in policy and implementation decisions. Notwithstanding, our study has made an important contribution by identifying what is and what is not in the policies and specific factors that may be contributing to the failure to address some critical pathways to enteric infection, management and prevention related to zoonotic, environmental and social determinant factors, which will inform not only research but policy updates and practice improvements.