Research & Publications
Explore her research publications and scholarly contributions drawn from academic, professional, and project-based work.
Publications
With 23+ publications and research outputs, Easter communicates complex findings with clarity, from evidence synthesis and data analysis to manuscript development and dissemination. Her career is grounded in a clear commitment: producing credible evidence that helps shape better health policies, smarter investments, and stronger health systems.
01
Women’s autonomy and maternal health decision making in Kenya: implications for service delivery reform - a qualitative study
The study investigates the role of women’s autonomy in shaping maternal health decision-making in Kenya, emphasizing how independence in choices around antenatal, delivery, and postnatal care directly improves service utilization and health outcomes. Using a mixed-methods approach, the authors found that women with greater autonomy were more likely to access antenatal care, skilled birth attendance, and postnatal services, while those constrained by socio-cultural norms, economic dependence, and limited spousal support faced significant barriers. The paper highlights that patriarchal structures and household power dynamics often restrict women’s ability to make timely health decisions, but spousal support and joint decision-making can enhance outcomes. Strengthening women’s autonomy through education, economic empowerment, and community-level interventions is essential for advancing maternal health in Kenya, while also noting that persistent gender inequalities and resource limitations remain critical challenges.
02
Budget Impact Analysis of Cervical Cancer Treatment in Kenya
This paper evaluates the budget impact of cervical cancer screening and treatment in Kenya, comparing a population-based screening program with ad hoc (point-of-care) screening. Using a Markov model and a health system perspective, the study found that population-based screening is both more cost-effective and yields better health outcomes. Specifically, annual costs for population-based screening were lower ($523 vs. $1,811), while quality-adjusted life years (QALYs) gained were higher (11.51 vs. 10.75), resulting in an incremental cost-effectiveness ratio of –$1,699 per QALY, indicating savings rather than added costs. Over a 20-year horizon, population-based screening reduced treatment costs significantly ($43.5 million vs. $57.6 million for ad hoc screening) and optimized resource use by detecting cases earlier, thereby avoiding expensive late-stage interventions. Systematic, population-based screening not only improves health outcomes but also alleviates financial burdens on Kenya’s healthcare system, making it a more sustainable and equitable policy option.
03
Comparison of Patient flow and provider efficiency of two delivery strategies for HPV- based cervical cancer screening in Western Kenya: a time and motion study.
This study compares patient flow and provider efficiency between two HPV-based cervical cancer screening strategies in rural Western Kenya: community health campaigns (CHCs) and government clinics. Using time-and-motion data from 12 communities, the researchers found that CHCs offered a much shorter, more efficient screening experience, with average visits lasting 42 minutes compared with 87 minutes at clinics. The difference was largely due to long registration wait times at clinics (36 minutes), while CHCs achieved faster throughput and more comprehensive group education sessions. Although provider efficiency at CHCs was lower due to idle time, patient efficiency was higher, meaning women spent less time waiting and more time actively engaged in screening. Overall, the study concludes that CHCs provide a more favorable model for scaling up cervical cancer screening in low-resource settings, as they reduce patient time burdens, improve satisfaction, and potentially increase uptake. For clinic-based programs, reducing registration delays and better aligning staffing with patient arrival patterns could improve efficiency and outcomes.
04
Comparison of the costs of HPV testing through Community health campaigns versus Home-based testing in rural western Kenya: A micro-costing study.
This study compares the costs of HPV screening delivered through community health campaigns (CHCs) versus home-based testing in rural Western Kenya, using a micro-costing approach from the health system perspective. Both strategies achieved similar mean costs per woman screened—$37.7 for CHCs and $37.1 for home-based testing—but relied on different resource mixes. CHCs required more capital inputs (23% of costs, such as tents and equipment) and higher outreach expenses, whereas home-based testing was more personnel-intensive (73% of costs) because community health volunteers had to visit households and notify women of results. CHCs reached more women overall, making them effective for broad population coverage, whereas home-based testing was more efficient in reaching women who had not participated in CHCs, particularly those with historically low screening rates. The study concludes that both models are viable and complementary: CHCs are better for scale-up and mass mobilization, while home-based testing ensures inclusivity and equity in access. Policymakers are encouraged to consider combining these approaches to maximize coverage, reduce barriers, and achieve cost efficiencies in cervical cancer prevention programs.
05
Cost of HPV screening at community health campaigns (CHCs) and Health Clinics in Rural Kenya.
This paper compares the costs of HPV-based cervical cancer screening delivered through community health campaigns (CHCs) versus government health clinics in rural Kenya, using prospective micro-costing methods. Conducted in 12 communities in Migori County, the study screened 2,899 women at CHCs and 2,042 at clinics. The mean cost per woman screened was lower at CHCs ($25.00) compared to clinics ($29.56). Clinics had higher personnel costs ($14.27 vs. $11.26) and capital inputs ($5.55 vs. $2.80), while CHCs had higher outreach costs ($3.34 vs. $0.17) due to more intensive mobilization activities. Screening and notification phases were more expensive in clinics, reflecting longer processes and higher staffing requirements. Sensitivity analyses suggested that reducing clinic staffing could bring costs closer to CHC levels. Overall, the study concludes that periodic, high-volume CHCs are a viable and cost-efficient strategy for scaling up cervical cancer screening in low-resource settings, as they mobilize larger numbers of women quickly and at lower cost than clinic-based approaches.
06
HPV-based cervical cancer screening in low-resource settings: maximizing the efficiency of community-based strategies in rural Kenya.
This study analyzes the efficiency of HPV-based cervical cancer screening delivered through community health campaigns (CHCs) in rural Kenya, focusing on costs per woman screened and factors influencing uptake. Conducted in Migori County in 2016, the micro-costing approach found that CHCs achieved costs ranging from $22.06 to $30.21 per woman screened, with efficiency strongly correlated to the absolute number of women screened rather than the proportion of the population reached. Key facilitators included door-to-door mobilization, stakeholder engagement, adequate staffing, and logistical support, while barriers such as religious beliefs, prior negative experiences with screening, and poor coordination among partners reduced efficiency. Contextual factors like campaign timing (e.g., avoiding harvest seasons) and integration with other reproductive health services also influenced outcomes. The study concludes that CHCs are a cost-efficient and scalable strategy for HPV screening in low-resource settings, but efficiency varies widely depending on community-specific conditions. Addressing modifiable barriers—such as improving coordination, tailoring education, and engaging local leaders—can further enhance uptake and sustainability of cervical cancer prevention programs.
07
Care seeking during pregnancy: testing assumptions behind Service Delivery Redesign for Maternal and Newborn Health in Kenya
This paper evaluates Service Delivery Redesign (SDR) for maternal and newborn health in Kakamega County, Kenya, testing whether its core assumptions hold true in practice. Using prospective survey data from over 19,000 women, the study examined delivery location choices, travel times, costs, and patient-reported quality of care. Results show that facility deliveries rose sharply from 50% in 2010 to nearly 90% in 2019, and that most women (70%) delivered at a different facility than initially planned during antenatal care. Out-of-pocket expenditures were slightly higher in hospitals (1351 Ksh) compared to primary health centers (964 Ksh), mainly due to medicines and supplies, while transport costs were modestly higher for hospital deliveries. Travel times and distances were similar across both settings (about 50 minutes and 15 km), and overall patient-reported quality scores did not differ significantly, though hospitals scored better on some subcomponents such as competence and willingness to explain. These findings support SDR’s assumption that hospital delivery is feasible and acceptable, but highlight challenges related to costs, coordination, and the consistent delivery of interpersonal quality. The study concludes that shifting deliveries to hospital “hubs” could improve emergency readiness without undermining patient experience, provided that financial and logistical barriers are addressed.
08
The Economic Costs of Tobacco-Related Illnesses in Kenya
This study provides a comprehensive estimate of the economic costs of tobacco-related illnesses (TRIs) in Kenya, combining direct healthcare expenditures with productivity losses. Conducted across four national referral hospitals, it focused on cardiovascular diseases, cancers, chronic obstructive pulmonary disease (COPD), and tuberculosis. Results show that the healthcare cost attributed to tobacco use was about US$396 million, with myocardial infarction accounting for the largest share (US$158.7 million), followed by peripheral arterial disease and stroke. Medication costs were the dominant driver, representing over 90% of direct medical expenses. Productivity losses due to morbidity and premature mortality contributed significantly, ranging from 27% to 48% of total economic costs. Overall, the total economic burden of tobacco use in Kenya was estimated between US$544.7 million and US$756.2 million in 2022, far outweighing the economic benefits of tobacco production and sales. The authors conclude that tobacco imposes a substantial strain on Kenya’s health system and economy, underscoring the urgent need for stronger enforcement of the Framework Convention on Tobacco Control and Kenya’s Tobacco Control Act (2007) to reduce consumption and prevent further health and economic losses.
09
Cost analysis of an intrapartum quality improvement package for improving preterm survival and reinforcing best practices in Kenya and Uganda
This paper analyzes the costs of implementing an intrapartum quality improvement package (PTBi) aimed at improving preterm survival in Kenya and Uganda, comparing it to a more minimal active control. The PTBi package included four components: data strengthening, a modified WHO Safe Childbirth Checklist, PRONTO simulation and team training, and quality improvement collaboratives. Using micro-costing methods, the study estimated incremental costs from a health system perspective under two scenarios: (1) implementation-level costs as observed in the PTBi study, and (2) hypothetical costs if integrated into Ministry of Health programming. Results showed that in Scenario 1, total costs were $1.11M in Kenya ($48.13 per birth) and $0.74M in Uganda ($17.19 per birth). In Scenario 2, modeled under public-sector implementation, costs dropped to $0.86M in Kenya ($23.91 per birth) and $0.28M in Uganda ($5.47 per birth), with annual maintenance costs of $16.36 per birth in Kenya and $3.47 per birth in Uganda. Personnel costs were the largest driver, accounting for over 70% of total expenditures. The study concludes that the PTBi package is feasible, cost-efficient, and potentially life-saving, with steady-state costs representing only 5–15% of total per-birth healthcare costs in these settings, making it a promising strategy for scaling up preterm survival interventions.
10
Estimating the economic impact of COVID-19 disruption on access to sexual and reproductive health and rights in Eastern and Southern Africa
This study estimates the economic impact of COVID-19 disruptions on sexual and reproductive health and rights (SRHR) services in Eastern and Southern Africa, with a focus on maternal and child health outcomes. Using the Lives Saved Tool (LiST) and national service coverage data, researchers calculated 1,335,663 life-years lost between 2019 and 2020, with 1,056,174 attributed to child mortality and 279,249 to maternal mortality. Countries with the highest case-fatality rates included the Democratic Republic of Congo, Burundi, and Tanzania. The monetized value of these losses amounted to US$3.6 billion, with Angola (US$777 million), South Africa (US$539 million), and the DRC (US$361 million) experiencing the largest economic impacts.The findings highlight that COVID-19 disruptions not only reversed progress in SRHR but also imposed high economic costs, deepening poverty and gender inequality. The authors recommend that countries strengthen health system resilience, integrate lessons from shock events, and prioritize investment in SRHR to mitigate future crises.
11
Impact of COVID-19 on the Utilization of Respiratory and Mental Health Services in Kenya.
This study shows that the COVID-19 pandemic significantly altered healthcare use in Kenya, reducing respiratory service visits while increasing demand for mental health care. Among children under five, pneumonia visits fell by 11%, upper respiratory infections by 10%, and other respiratory diseases by 84%, though tuberculosis services rose sharply by nearly 292%. For those over five, pneumonia visits dropped by 8%, upper respiratory infections by 19%, other respiratory diseases by 35%, and tuberculosis by 14%. In contrast, mental health services expanded in most counties, with Elgeyo Marakwet recording a 383% increase, Garissa 218%, and Tharaka Nithi 209%, while only nine counties saw declines. These shifts were driven by home-based COVID care, preventive measures like masking and distancing, fear of hospitals, and the adoption of telemedicine, which helped sustain mental health support. Overall, the findings highlight how the pandemic disrupted traditional care pathways while also accelerating the adoption of new service delivery models.
12
Impact of COVID-19 on the Utilization of Respiratory and Mental Health Services in Kenya.
This study shows that the COVID-19 pandemic significantly altered healthcare use in Kenya, reducing respiratory service visits while increasing demand for mental health care. Among children under five, pneumonia visits fell by 11%, upper respiratory infections by 10%, and other respiratory diseases by 84%, though tuberculosis services rose sharply by nearly 292%. For those over five, pneumonia visits dropped by 8%, upper respiratory infections by 19%, other respiratory diseases by 35%, and tuberculosis by 14%. In contrast, mental health services expanded in most counties, with Elgeyo Marakwet recording a 383% increase, Garissa 218%, and Tharaka Nithi 209%, while only nine counties saw declines. These shifts were driven by home-based COVID care, preventive measures like masking and distancing, fear of hospitals, and the adoption of telemedicine, which helped sustain mental health support. Overall, the findings highlight how the pandemic disrupted traditional care pathways while also accelerating the adoption of new service delivery models.
13
Point‐of‐care viral load tests to detect high HIV viral load in people living with HIV/AIDS attending health facilities. A Systematic review.
This Cochrane review found that point‑of‑care viral load tests are highly accurate for detecting high HIV viral load in people on antiretroviral therapy, with a pooled sensitivity of 96.6% and specificity of 95.7% at the WHO threshold of ≥1000 copies/mL. Based on 18 studies (over 10,000 participants), tests such as Xpert HIV‑1 and SAMBA HIV‑1 Semi‑Q performed reliably across diverse settings, offering faster results than central laboratory testing. While reporting quality was sometimes unclear and few studies were conducted truly at the bedside, the evidence shows POC testing can support timely ART decisions, reduce delays, and strengthen HIV care in resource‑limited settings.
14
Role of Social Health Insurance in Achieving Universal Health Coverage
This paper examines the role of social health insurance (SHI) in achieving universal health coverage (UHC) in Kenya, with a focus on the National Hospital Insurance Fund (NHIF). Using National Health Accounts (2016/17–2018/19) and household health expenditure surveys, the study shows that SHI’s share of current health expenditure rose from 10.3% to 13.8%, while out‑of‑pocket payments remained high at about 24%. Despite NHIF covering nearly 90% of insured households, overall insurance penetration was only 19.9% in 2018, with sharp inequities: just 4.5% coverage among the poorest quintile versus 42.3% among the richest. Barriers to care include self-medication (45%) and lack of money (19%). Perceived quality of care improved, with 68% of households reporting good services in 2018, up from 57% in 2013. The study concludes that NHIF must expand coverage, reduce out‑of‑pocket spending, and align reforms with strategic purchasing to improve equity, efficiency, and quality in Kenya’s health system.
15
Situation Analysis on the Quality of Maternal and Child Health in Nairobi and Garissa County in Kenya
This study was a situational analysis of maternal and child health (MCH) services in Nairobi and Garissa counties, highlighting persistent vulnerabilities that undermine the quality of care. Using mixed methods with surveys, observations, and focus groups, the findings show that while MCH services such as family planning, antenatal care, and immunization are widely available, critical gaps remain. These include poor access to facilities, inadequate medicines, shortages of essential supplies, weak infrastructure, and limited capacity for emergency obstetric and neonatal care at lower-level facilities. Women reported preferring trained health workers over traditional birth attendants due to expertise and safety, yet many facilities lacked functional ambulances, equipped theaters, or blood storage capacity. Both patient-related barriers (distance, cost) and organizational challenges (insufficient equipment, delayed NHIF reimbursements) hinder service quality. The study concludes that strengthening supply chains, expanding infrastructure, ensuring the consistent availability of maternal medicines, and investing in health workers' capacity are essential to reducing maternal and child mortality in high-burden counties such as Nairobi and Garissa.
16
Investment case for primary health care in low- and middle-income countries: A case study of Kenya
This is an investment case for primary health care (PHC) in Kenya, showing that scaling up PHC yields major health and economic benefits. Using cost–benefit analysis, Activity-Based Costing, and the OneHealth Tool, researchers estimated that implementing Kenya’s PHC Strategic Framework (2019–2024) would cost KSh 1.65 trillion (USD 15.6 billion) over five years, with human resources accounting for 75% of the total cost. The interventions could avert 64.4 million DALYs, prevent over 25,000 child deaths, 6,600 maternal deaths, and 15,000 stillbirths, while reducing burdens from stunting, anemia, malaria, TB, and NCDs. Financially, PHC investments would generate Ksh 21.5 trillion (USD 204 billion) in savings, with a benefit–cost ratio of 16:1—meaning every $1 invested saves up to $16 in future health spending. The study concludes that prioritizing PHC financing is not only vital for universal health coverage but also a driver of economic growth, urging governments and partners to expand PHC networks and strengthen community-level care.
17
Evaluating a community-based cervical cancer screening strategy in Western Kenya: a descriptive study. Journal
This study evaluated a community-based cervical cancer screening campaign in Ngodhe, Migori County, Kenya, using self-collected HPV tests. Out of about 870 eligible women, 267 attended the four-day campaign, and 255 provided samples. Results showed that 19% tested positive for HPV, with younger age being the only significant predictor of positivity. While three-quarters of participants were successfully notified of their results, only 51% of HPV-positive women presented for treatment, highlighting a major gap in linkage to care. Women reported high acceptability of self-collection, with nearly all saying they would test again and recommend it to others. The study concludes that community health campaigns can substantially increase screening uptake compared to national averages, but strengthening follow-up and treatment pathways is essential to maximize impact.
18
Human papillomavirus self-sampling versus provider-sampling in low- and middle-income countries: a scoping review of accuracy, acceptability, cost, uptake, and equity.
This scoping review of 124 studies (over 164,000 women) found that HPV self-sampling in LMICs is widely acceptable, cost-effective, and often preferred to provider-sampling, with most participants valuing privacy, convenience, and autonomy. Accuracy varied, with sensitivity ranging from 37.5–96.8% and specificity from 41.6–100%, while costs were generally lower and uptake higher for self-sampling in most studies. However, evidence gaps remain around equity factors such as age, education, and residence, which were mentioned but rarely analyzed. The review concludes that self-sampling can expand cervical cancer screening in resource-limited settings, but further research is needed on accuracy comparisons, transport methods, and equity impacts.
19
Technical Factors Influencing Adoption of Data Analytics in Maternal Health Programming Among Health Managers in Kericho and Vihiga Counties, Kenya.
This study explored the technical factors influencing the adoption of data analytics in maternal health programming among health managers in Kericho and Vihiga counties, Kenya. Findings showed that the availability of standard data collection tools, especially maternal health-specific forms, strongly influenced adoption, while IT infrastructure alone did not significantly affect usage. Most managers (88%) engaged in data analysis during collection, but fewer advanced to modeling or interpretation, and many lacked a defined frequency for analysis. Key barriers included inadequate training (90%), limited human resources (71%), and reliance on manual data processing (58%). Although tools such as SPSS, Excel, and Tableau were available, access to and use of them varied widely. Overall, the study highlights that skills, resources, and organizational commitment are more critical than infrastructure alone, and calls for investment in training, integration of digital tools, and sustainable funding to strengthen maternal health outcomes.
20
Individual Determinants of Data Analytics Adoption in Maternal Health Programs: A Study among Health Managers in Kericho and Vihiga Counties, Kenya.
This study examined individual determinants of data analytics adoption among health managers in maternal health programs in Kericho and Vihiga counties, Kenya. Using the Diffusion of Innovation and Technology Acceptance Models, it found that education level, years of experience, age, and professional cadre significantly influenced adoption, while gender had less consistent effects. Managers with higher education, longer service, and senior roles were more likely to engage with data analytics, whereas younger or less experienced staff showed lower uptake. Training across all education levels improved data quality outcomes, underscoring the importance of capacity-building and tailored interventions to strengthen data-driven decision-making. Overall, the study highlights that education and experience are the strongest predictors of adoption, suggesting that targeted training and support for less-experienced cadres can enhance maternal health outcomes through improved use of analytics.
21
Assessing the Level of Adoption of Data Analytics Utilization in Maternal Health Programming Among Health Managers: A Case Study of Kericho and Vihiga Counties, Kenya.
This study assessed the level of data analytics adoption in maternal health programming among health managers in Kericho and Vihiga counties, Kenya, using the analytics maturity model. Results showed strong progress at the foundational (66% → 87%) and descriptive (70% → 90%) levels, indicating improved capacity for basic data collection and trend analysis. However, adoption remained absent at the diagnostic and cognitive levels (0%), with only modest gains in predictive (2% → 6%) and prescriptive (3% → 4%) analytics. The findings highlight that while health managers are increasingly using data for routine monitoring, advanced analytics for diagnosing causes, forecasting risks, and prescribing interventions are still underutilized. The study concludes that targeted training, structured review processes, and investment in advanced analytics are needed to strengthen evidence-based decision-making and improve maternal health outcomes.
22
Influence of institutional support and organizational culture on HIV and NCD integration
This qualitative study in Nakuru County, Kenya, explored how institutional support and organizational culture shape the integration of HIV and non‑communicable disease (NCD) services. Interviews with 99 healthcare providers revealed that strong institutional backing—through leadership commitment, resource allocation, infrastructure, staff capacity building, and monitoring—was critical for successful integration. Equally important was a supportive organizational culture marked by adaptivity, innovation, teamwork, staff empowerment, and performance monitoring, which improved patient workflow, reduced wait times, enhanced continuity of care, and lowered stigma. Facilities that embraced these values achieved more efficient service delivery and better patient outcomes. The study concludes that integration efforts thrive when institutions invest in resources and foster cultures of collaboration, innovation, and patient‑centredness, offering lessons for scaling HIV–NCD integration in other high‑burden settings.
23
Productivity benefits of treatment of depression and post-traumatic stress disorder in Kenya
This study evaluated the productivity benefits of treating depression and PTSD in Kenya through the SMART‑DAPPER trial. Over 2,100 adults in public primary care were randomized to interpersonal psychotherapy (IPT) or fluoxetine, delivered by trained non‑specialists. Both treatments significantly improved economic outcomes: the proportion of participants earning a monthly income rose (IPT: 54.9% → 59.8%; fluoxetine: 54.5% → 61.5%), average monthly income increased (IPT: +KES 1920 / 46 Intl$; fluoxetine: +KES 1350 / 31 Intl$), and absenteeism fell (IPT: −1.5 days/month; fluoxetine: −1.9 days/month). Presenteeism (reduced work efficiency) dropped more with fluoxetine (−4.8 days) than IPT (−3.3 days). Gains were strongest among patients achieving clinical remission. The study concludes that scaling evidence‑based mental health treatments via non‑specialist providers can enhance both health and economic productivity, supporting Kenya’s universal health coverage goals.
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