To what extent are vulnerability issues included and addressed in Kenya's health and immunization policy documents? A systematic review of documents

i. Eligibility criteria

In this review, a policy document was defined as an action plan, a guideline or a planning document that contains the government’s intention concerning a particular health issue(s), including specific policies, guidelines, strategic plans and laws¹⁵. The review included the following categories of documents: health sector policy documents (documents that cut across the entire health sector), immunization-specific documents (documents which focus on the immunization programme in Kenya), documents in English language and those developed between 2000 (to correspond with the establishment of GAVI, which has played a key role in promoting access to vaccines in most developing countries like Kenya) to 2023.

ii. Sources of the policy documents

We conducted online searches of relevant websites and general Google searches to retrieve policy documents. The websites that were searched included the official Kenyan Ministry of Health website (https://www.health.go.ke/), websites of international organizations working around childhood immunization namely; United nations children Fund (UNICEF) (https://www.unicef.org/), Global Alliance for Vaccines and Immunization (GAVI) (https://www.gavi.org/), World Health Organization (WHO) (https://www.who.int/) and Save the Children Kenya (https://kenya.savethechildren.net/). Since this review is part of a broader primary study within Kilifi County in Kenya, we also requested relevant policy documents from Kilifi County Department of Health. Reference lists of the documents were also searched to identify additional policy documents.

iii. Search strategy

We used the following Boolean phrases for the online searches: vaccine OR vaccin* OR immunization OR immuniz* AND policy OR guideline OR plan AND Kenya, health AND policy OR guideline OR plan AND Kenya expanded programme on immunization OR EPI OR Kenya expanded programme on immunization or KEPI. In addition, we searched manually through the resources sections of the specific websites mentioned above.

iv. Document selection process

EO manually screened the documents retrieved from the different sources based on the inclusion criteria. The titles and executive summaries of documents (where applicable) were screened to identify policy documents that cut across the entire health sector or were immunization-specific and created since the establishment of GAVI in 2000 up until 2023. In addition, a search of terms including vulnerability, immunization, and vaccination within the documents was conducted. Documents that were for other health sector programmes and/or created before 2000 were excluded. The list of documents identified as eligible for review was then shared with the other reviewers (PC, CJ, DM and DK). The team met to discuss the appropriateness of the documents identified as eligible, and a consensus was reached on documents to be included for final review.

V. Data collection process and synthesis

Data were extracted from the included documents using a data extraction tool¹⁶ prepared as a template in Excel. Each row of the tool contained a document, while the individual columns captured the type of information to extract from the documents. Extracted data included general information about the documents, namely, the full title of the document, author(s), date of publication, intended users/audience, actors (persons, groups or organizations involved in and influencing the formulation and implementation of the document) and a summary of document content. In addition, information related to how vulnerability was defined, any components of vulnerability and strategies suggested to address vulnerability were identified and extracted. The extracted data were then organized thematically to address the review objectives; how vulnerability issues are conceptualized/defined, aspects considered in the documents and strategies proposed to address vulnerability issues.

1. Study selection

A total of 88 documents were retrieved through online searches, and an additional 11 from other sources, such as reference lists and stakeholders from the Kilifi County Department of Health. Of the 99 documents retrieved, 78 were excluded because they were either not health sector documents, for other health programmes apart from immunization, or the document didn’t have any information on key issues under review. Twenty-one documents were included for final review and data extraction. Figure 1 summarizes the process of document selection.

Figure 1. Flow of the document selection process.

This figure shows the systematic process we followed to select the policy documents for review. *EPI: Expanded Programme on Immunization.

2. Categories of documents reviewed

A total of 21 policy documents were reviewed. Of these, 15 were categorised as health sector documents, 4 were immunization-specific documents, and two were legislative documents as summarized in Table 1.

3. Content of documents reviewed

a. Content of general health sector documents. Of the 15 health sector documents reviewed, 13 explicitly mentioned the term/phrase vulnerable group/persons and/or vulnerability. In the other two documents, economic or social characteristics of groups of people, such as ‘the poor’, were used, but the term “vulnerable” and/or “vulnerability” were not mentioned. The documents in which the terms vulnerability, vulnerable groups and vulnerable persons were mentioned in the objectives, policy directions, targets and implementation plans included the Transforming health systems for universal care: vulnerable and marginalized groups; the Kenya primary healthcare strategic framework 2019–2024 and the Kenya health sector strategic plan 2018–2023 as shown in Figure 2. A total of 136 mentions of the terms “vulnerable” and/or “vulnerability” were made in the Transforming health systems for universal care: vulnerable and marginalized groups document, 13 mentions in the Kenya health sector strategic plan 2018–2023 and Kenya primary healthcare strategic framework 2019–2024.

Figure 2. Number of times the terms vulnerability/vulnerable appear in reviewed general health sector documents.

This table shows how many times the term vulnerability or vulnerable was mentioned in the general health sector policy documents reviewed.

In most of these health sector documents, while the terms were widely used, limited information was provided about issues facing the vulnerable groups or what contributed to their vulnerability. For instance, in the section on equitable access to health care, the Kenya national eHealth policy 2016–2030, states that eHealth will provide the health system with the ability to reach vulnerable population groups in low-resource settings. However, the document lacks details on who these vulnerable groups are. Similarly, in the Kenya health financing strategy 2020–2030, vulnerability is mentioned in the forward as well as the goal and objectives sections to indicate that there will be effective safety nets for the poor and the vulnerable, but there is no further discussion or specification of who is included in the ‘vulnerable’ or the safety nets to be put in place or how they will be realized. The Transforming health systems for vulnerable and marginalised groups plans 2020–2021 was the only document whose content exclusively focused on the vulnerable. The vulnerable groups discussed in the document were based on the World Bank’s operational policy 4.10 on indigenous people, also known as vulnerable and marginalised groups (VMGs). Examples of these groups were the Illchamus and Endorois of Baringo county, Ogiek of Mt. Elgon Forest, Malakote/Waliwana of Tana River County among others.

b. Content of immunization specific documents. In the four immunization documents reviewed, there were also no detailed discussions about vulnerable groups. One of these documents was the most recent national immunization policy guideline (Kenya national immunization policy guidelines 2023) and while there was mention of vulnerable groups, very little information was provided on the challenges that such groups might experience related to immunization services. Surprisingly, the terms vulnerable and vulnerability were not used in the comprehensive multiyear plans for immunization (CMYPs) 2011–2015 & July 2015–June 2019; the phrase used was “hard to reach populations”. In both documents, challenges that influence access and uptake of immunization were generally discussed. For example, in both the CMYPs, the following were highlighted as the general challenges to vaccine access and uptake: inadequate financing and human resources, inaccessibility of immunization services, missed opportunities, lack of technical capacity and communication challenges to create demand for immunization services.

c. Content of legislative policy documents. The legislative documents reviewed in this study were the Kenyan Constitution 2010 and the Health Act No. 21 of 2017. In the constitution, the term vulnerability was captured in Article 20 on the application of the Bill of Rights and Article 21, which focuses on the implementation of rights and fundamental freedoms. Article 20(5b) states that “in allocating resources, the State shall give priority to ensuring the widest possible enjoyment of the right or fundamental freedom having regard to prevailing circumstances, including the vulnerability of particular groups or individuals.” Further under Article 21(3) on the implementation of rights and fundamental freedoms, women, older members of society, persons with disabilities, children, youth, members of minority or marginalised communities, and members of certain ethnic, religious or cultural communities were listed as vulnerable groups. The Health Act No. 21 of 2017 reiterates the provisions of the vulnerable groups as enshrined in Article 21 of the constitution, which states that “all State organs and all public officers have the duty to address the needs of vulnerable groups within society...”

2. Framing/Conceptualization of vulnerability in the reviewed documents

In the Kenya primary healthcare strategic framework 2019–2024 vulnerability was defined as “the degree to which a population, individual or organization is unable to anticipate, cope with, resist and recover from the impacts of disasters” while vulnerable populations were defined as “a group of people such as children, pregnant women, elderly people, malnourished people, and people who are ill or immunocompromised, socioeconomically disadvantaged who are particularly vulnerable when a disaster strikes, and take a relatively high share of the disease burden associated with emergencies”. A common trend across the other documents was the mention of groups considered vulnerable, as summarized in Table 2 (extended data), implying that vulnerability was associated with certain groups of people. Whereas none of the documents defined different types of vulnerability, we developed four typologies of vulnerability from the groups listed in the documents, namely vulnerability as a socio-economic condition, vulnerability as a biological condition, vulnerability as a health condition and vulnerability as a physical location.

a. Vulnerability as a socio-economic condition. Across all the documents reviewed, vulnerability seemed to emanate from people’s socio-economic positions/conditions. This was depicted by a range of socio-economic factors implied by the vulnerable groups listed across the policy documents. The factors included ethnicity, education, occupation, social class and income. As such, the most common vulnerable groups mentioned in the documents were the poor, sex workers, the less educated, refugees, nomadic populations, and those living in informal settlements. Other broad groups namely marginalized communities and minorities were also used, but specific groups under these were not provided.

b. Vulnerability as a biological condition. A second typology of vulnerability implied in the reviewed documents relates to physical and physiological conditions. The main factors associated with this type of vulnerability included age and physical disability. Some of the vulnerable groups categorized under this included the elderly, children, adolescents, women and persons living with disability.

c. Vulnerability as a health condition. In the documents, vulnerability was also implied to emanate from health conditions. As such, individuals suffering from certain specific diseases were considered vulnerable. Categories of vulnerable individuals under this typology include chronic health conditions like HIV, malnourished individuals, and those who abuse drugs.

d. Vulnerability as a physical location/vulnerability of places. Lastly, vulnerability was associated with certain geographical locations. Thus, communities and/or population groups residing in those locations were considered vulnerable. Examples of these included far-to-reach/hard-to-reach areas, remote/rural areas, urban informal settlements and insecurity affected settings. However, unlike the two other types of vulnerability, this third type was only prominent in the immunization-specific documents compared to the general health sector documents, where only five documents identified vulnerable groups according to their geographical location. None of the legislative documents identified vulnerable groups under this category.

1. Measures/strategies to address vulnerability issues

Various measures were proposed in the reviewed documents to address the needs of the groups that had been categorized as vulnerable. We grouped the key measures into the following categories:

a. Rights-based approach. A rights-based approach to provision of health services was proposed to ensure that health related rights of the vulnerable are respected and protected. This was proposed in the following documents: the Health Act No.21 of 2017, Kenya Health Policy, the National Health Sector Strategic Plan 2005–2010 and UHC policy 2020–2030. The Health Act No.21 of 2017 stipulates that the rights of vulnerable groups should be protected, respected and promoted as per Article 21 of the Kenyan constitution, ensuring that their health-related rights and interests are realized. In the Kenya Health Policy 2014–2030, one of the obligations for the policy is a progressive realization of rights to health, as illustrated in the clause below.

b. Research to support evidence-based policy for the vulnerable and their health needs. A second measure proposed was conducting research focusing on the needs of the vulnerable. The Health Act No.21 of 2017 states that due regard will be paid to the health needs of the vulnerable when identifying priorities for health research. In the Kenya health policy, one of the policy orientations on research and development specifically states that “MOH will prioritise research in order to support evidence-based policy and intervention formulation, identifying gaps and critical factors for special needs for vulnerable groups especially the women, children and the elderly” Kenya health policy 2014–2030; pg 51. Closely related to research was the proposal to conduct risk mapping and vulnerability assessments to manage emergency disasters that may negatively affect vulnerable groups (Kenya Health Sector Strategic Plan and Transforming Health System: Achieving Universal Health Coverage by 2022).

c. Removing financial barriers to health access by vulnerable groups. Another measure captured in some of the documents is the reduction of financial barriers that hinder vulnerable populations/groups from accessing health services. In the Sessional Paper No. 4 of 2012 on National Pharmaceutical Policy, this could be achieved by progressively eliminating user fee payments at the point of health service use for vulnerable groups, health insurance and subsidies. Further strategies were proposed in the National Health Sector Strategic Plan 2005–2010 and these included making investments that benefit the poor, improving resource allocation and financial targeting to underserved and poor areas as well as a gender focus¸ increasing funding as part of pro-poor agenda, define datasets to measure regional disparities, developing common financial tools and renting out underutilized facilities to private providers to cushion the vulnerable from high cost of health care.

d. Strengthening access to primary health services. In the Kenya primary healthcare strategic framework, one of the key objectives was to strengthen access to primary health services for the vulnerable groups. This was to be attained by developing a health promotion framework as well as guidelines, policies and standards for vulnerable population; establishing community rehabilitation, palliative, rescue centres and home-based care and enhancing their linkages with facility-based rehabilitation, palliative care centres, the community and other relevant sectors.

e. Conducting outreach activities. All the immunization policy documents reviewed identified conducting integrated outreaches as the main measure proposed to reach the vulnerable groups. For instance, in the national policy guidelines on immunization 2013 and 2023, the only explicit strategy to increase access for groups considered as vulnerable, such as zero-dose and under vaccinated children is to conduct targeted immunization outreach activities integrated with other maternal and child survival services in areas known to have such groups.

Limitations

Whereas this document review was not a systematic review of published literature, it highlights the current state of vulnerability issues in the context of healthcare policy in Kenya; information that can be useful in improving the current policies to be more comprehensive. Although every effort was made to secure all relevant documents for the review, we recognise that we might not have included all the relevant policy documents because the majority of the included documents were those publicly available online. In addition, we were only able to receive few documents from stakeholders.