Towards "Zero by 30", the Kenyan case: a systematic exploration of barriers to rabies policy implementation through systems thinking.

Abstract

INTRODUCTION: Rabies is a neglected tropical disease (NTD) that disproportionately affects marginalized communities, despite the availability of effective vaccines. In response, the "Zero by 30" global strategic plan aims to eliminate dog-mediated human rabies deaths by 2030. However, localized barriers such as underreporting, fragmented vaccine supply and insufficient governance often impede progress, particularly for settings in Kenya. METHODS: To address these complexities, we employed qualitative system dynamics and group model building (GMB). We combined data from expert interviews (34 participants), field observations (five locations), and GMB workshop discussions (20 participants) to identify the feedback loops that link surveillance capacity, effective vaccinations, trust, prioritization and budget allocations in Kenya's health and veterinary sectors. This approach allowed us to map the interdependencies that lie at the basis of rabies persistence and to pinpoint systemic entry points for policy intervention. This study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) to document the methods. RESULTS: Our findings reveal multiple reinforcing and balancing loops involving vaccine accessibility, surveillance capacity and workforce readiness. Underreporting, budget deficits and the risk of so-called success-induced reductions in vigilance repeatedly surfaced as key impediments. Additionally, economic considerations (for example, high out-of-pocket costs and reliance on donor funds) undermine sustained rabies-control efforts. These dynamics directly intersect with the "Zero by 30" objectives, highlighting the need for stable, multiyear funding, cross-sectoral collaboration and innovative vaccination strategies (for example, streamlined pre-exposure prophylaxis regimens). CONCLUSIONS: Stakeholder-validated causal-loop diagrams show that Kenya's rabies-control bottlenecks - such as vaccine stock-outs, fragmented surveillance and fluctuating political will - form self-reinforcing cycles that stall progress toward "Zero by 30". By exposing these dynamics, the study identifies policy entry-points that can break the cycles - shifting the conversation from what fails to why it persists. Therefore, the study offers decision-makers a structured systems map for turning systemic insights into effective, context-specific action.