A retrospective cohort study to quantify the contribution of health systems to child survival in Kenya: 1996-2014.

Globally, the majority of childhood deaths in the post-neonatal period are caused by infections that can be effectively treated or prevented with inexpensive interventions delivered through even very basic health facilities. To understand the role of inadequate health systems on childhood mortality in Kenya, we assemble a large, retrospective cohort of children (born 1996-2013) and describe the health systems context of each child using health facility survey data representative of the province at the time of a child's birth. We examine the relationship between survival beyond 59 months of age and geographic distribution of health facilities, quality of services, and cost of services. We find significant geographic heterogeneity in survival that can be partially explained by differences in distribution of health facilities and user fees. Higher per capita density of health facilities resulted in a 25% reduction in the risk of death (HRR = 0.73, 95% CI:0.58 to 0.91) and accounted for 30% of the between-province heterogeneity in survival. User fees for sick-child visits increased risk by 30% (HRR = 1.30, 95% CI:1.11 to 1.53). These results implicate health systems constraints in child mortality, quantify the contribution of specific domains of health services, and suggest priority areas for improvement to accelerate reductions in child mortality.