Barrier and Strategy Prioritization for Ear and Hearing Care in Kenya

Abstract

Hearing loss is a growing global public health challenge, affecting more than 430 million people worldwide and projected to reach nearly 700 million by 2050.1 In children, unaddressed hearing loss can delay speech and language, impair educational achievement, and lead to social and economic disadvantage.1 Critical aspects of ear and hearing care (EHC) include early identification of hearing loss, hearing amplification, aural habilitation, and psychosocial care. Unfortunately, EHC services are scant and inequitable in low- and middle-income countries (LMICs). In Kenya, service delivery remains concentrated in urban private facilities, and many children face major geographic and financial barriers to access. Affordable hearing devices and cochlear implants are largely unavailable, referral pathways are insufficient, and overall health care workforce numbers are low.The World Health Organization (WHO) provides a useful framework to analyze these systemic barriers. Its 6 health system pillars—service delivery, health workforce, health information systems, medical products and technologies, financing, and stewardship/governance—provide a lens through which gaps in EHC can be better understood.2 Notably, Kenya has demonstrated commitment to addressing these gaps by developing an EHC National Strategy, recognizing audiologists and speech-language pathologists within its national scheme of service, as well as appointing an EHC focal person and technical working group within its Ministry of Health.3This article presents results of a national key person workshop in September 2023 to apply a participatory process to identify critical barriers and relevant implementation strategies to address gaps in EHC in Kenya. By aligning results with WHO’s pillars, we provide an example of a process and framework by which systems-level barriers may be identified, prioritized, and addressed in other LMICs facing similar challenges.Using an implementation barriers toolkit,4 21 workshop participants composed of Kenyan clinicians, policymakers, and economists discussed barriers and strategies to improve EHC nationally. Workshop participants listed barriers to screening, diagnosis, and treatment. Barriers were scored in order to identify priorities using a 4-point Likert scale (1 = least significant, 4 = most significant) for the following criteria: (1) criticality/importance (extent to which a barrier affects EHC provision), (2) pervasiveness/ubiquity (regularity at which a barrier impacts EHC), (3) chronicity/duration (length of time a barrier affects implementation), and (4) equity/impact on vulnerable groups (extent to which a barrier contributes to inequitable implementation).4 Each of the selected barriers were high scoring (Table 1), suggesting a need for confronting barriers in parallel. Indeed, participants agreed that strategies should address scored barriers simultaneously rather than sequentially, prioritizing expanding equipment and human resources as well as increasing knowledge and awareness.To facilitate interpretation and link findings to system-level reforms, participants prioritized barriers, and strategies were mapped onto the WHO health system pillars. This framework provides a structured lens through which the results of the prioritization process are presented.Participants identified lack of knowledge and awareness as a major barrier, particularly in rural areas, in which gaps were most pronounced. They noted that many frontline clinicians, as the first point of contact of primary health care, did not know how to access EHC services. Additionally, they often do not receive training in EHC and, therefore, are poorly equipped to identify early signs of childhood hearing loss or counsel caregivers effectively.To address these challenges, participants emphasized the need for training programs focused on hearing screening, referral pathways, and caregiver counseling. They proposed training community health promoters (CHPs) to conduct hearing screening, raise awareness, educate caregivers, and facilitate referrals, thereby expanding access and reducing workload of frontline clinicians. Providing this training to CHPs could enable them to be an important part of public health messaging on early signs of hearing loss, the benefits of early screening, and where families can access services.Participants further highlighted limited availability of specialists, scoring high on criticality and equity due to inequitable distribution between urban and rural areas. Audiologists and speech-language pathologists were reported to be particularly scarce and concentrated in urban private facilities, leaving rural areas and public facilities underserved. Participants also noted many clinicians lacked the expertise to use available diagnostic equipment, compounding inequities.Strategies proposed to address these gaps included expanding short-course and advanced specialty training programs for clinicians; task shifting hearing screening to CHPs and midwives to facilitate universal newborn screening and allow specialists to focus on diagnosis and treatment; and collaboration with national and county governments to recruit, train, and deploy personnel equitably across both urban and rural areas. Participants also noted that integrating hearing screening into midwives’ existing maternal and newborn care services would require an economic evaluation to inform policy decisions.Participants identified service delivery challenges as barriers scoring high on pervasiveness and chronicity. They emphasized that EHC services were fragmented and concentrated in urban private facilities, leaving rural populations with limited access and delayed care. Weak referral pathways were also highlighted as a barrier, resulting in children with suspected hearing loss being lost to follow-up.To strengthen service delivery, participants recommended integrating EHC into existing health services, such as immunization programs and maternal-child health clinics. Embedding hearing screening within these routine services was viewed as a potentially cost-efficient way to increase coverage, enable earlier detection, and reduce the long-term effects of unaddressed hearing loss. In addition, participants identified CHPs as a critical link in strengthening referral pathways to ensure that children identified in the community could be promptly connected to higher-level diagnostic and treatment services as indicated.Inadequate access to diagnostic equipment was a critical barrier for screening and diagnosis. Few facilities, primarily in urban centers, have functioning audiological devices, and even where equipment exists, maintenance and calibration costs restrict use. For treatment, similar challenges applied to the availability of hearing aids and cochlear implants, which remain limited and costly.Advocacy to elevate EHC as a public health priority and mobilize resources for equipment purchase and maintenance was cited as key strategy. Public-private partnerships (PPPs), supported by Kenya’s Public Private Partnership Act (2021),5 were highlighted as vehicles to bridge gaps. Although PPPs have traditionally emphasized physical infrastructure, participants pointed to operations-oriented models, such as the Isiolo County–Living Goods project,6 as examples for equipping clinicians and extending community outreach.Affordability was identified as a barrier to treatment. Imported hearing aids and cochlear implants face tariffs and value-added tax, and limited National Health Insurance Fund (NHIF) coverage means most families pay out-of-pocket. Unreliable donations further limit supply.Subsidies and tax exemptions for hearing amplification devices, expansion of NHIF coverage, and integration of EHC into maternal-child health services were strategies recommended to reduce costs. Participants also noted PPPs could facilitate reduced importation and distribution costs, improving availability in underserved areas.Leadership was seen as essential to overcoming barriers. Kenya’s progress in EHC national strategy development, recognition of professional cadres, and establishment of national leaders in EHC is laudable. Nonetheless, governance plays a key role in sustaining or constraining implementation.Strategies proposed included advocacy at both national and county levels to secure political prioritization of EHC, alignment of strategies with universal health care reforms, and structured engagement of decision-makers and private sector partners to ensure long-term sustainability.The barriers and strategies to improve EHC systems described here are not unique to Kenya. In South Africa, lack of knowledge, lack of physical infrastructure, affordability, and availability of care are identified as barriers to EHC services and access.7–9 Nigeria’s EHC national strategy seeks to address similar barriers.10 The cost of EHC compounded by the lack of insurance coverage in Kenya mirrors experience in other LMICs.11,12 The cost of hearing devices and equipment limits the financial feasibility of EHC in LMICs, and without government subsidies, these interventions remain inaccessible.11,13–15 The need for increased advocacy for comprehensive insurance coverage has been emphasized globally to reduce out-of-pocket costs.14,15 Inadequate human resources, especially in rural areas, is a globally widespread barrier.1 Moreover, lack of specialists is a major challenge to expanding EHC in other countries.11,16In Kenya, barriers to EHC are generally more pronounced in rural than in urban areas, highlighting a structural urban-rural inequity in access to services.3 In 2013, Kenya implemented a decentralization framework to improve access to health service delivery in rural settings, emphasizing allocating funding and governance to counties.17 However, the decentralization of EHC specifically has lagged, and services remain largely absent outside of urban centers.17 Persistent financing challenges continue to limit counties’ ability to procure equipment, expand diagnostic capacity, and deploy specialists.17 The development of Kenya’s EHC strategic plan signals a strong policy commitment to improving services, and intentional devolution of governance pertaining to EHC may facilitate progress.By using a barrier prioritization process and the WHO pillars to inform this work, Kenya has created a plan to build a more resilient and accessible EHC system. Adopting a similar approach may translate to EHC strengthening in other LMICs.We thank all members of the Kenya Ear and Hearing Care Technical Working Group who attended and participated in the key person workshop. We would like to acknowledge Dr Anjuli Wagner and Dr Cyrus for sharing their material, which provided valuable insights into the barrier prioritization method referenced in this study.