“If the Big Fish are Doing It Then Why Not Me Down Here?”: Informal Fee Payments and Reproductive Health Care Provider Motivation in Kenya

Abstract

Informal fees are payments made by patients to their health care provider that are over and above the official cost of services. Payments may be motivated by a combination of factors such as low supervision, weak sanctions, and inadequate provider salaries. The practice of soliciting informal fees from patients may result in restricted access to medical care and reduced care‐seeking behavior among vulnerable populations. The objective of this study is to examine nuanced health care provider perspectives on informal fee payments solicited from reproductive health patients in Kenya. We conducted in‐depth semistructured interviews in 2015–2016 among a sample of 20 public and private‐sector Kenyan health care workers. Interviews were coded and analyzed using an iterative thematic approach. More than half of participants reported that solicitation of informal fees is common practice in health care facilities. Providers reported low public‐sector wages were a primary driver of informal fee solicitation coupled with collusion among senior staff. Additionally, patients may be unaware that they are being asked to pay more than the official cost of services. Strategies for reducing this behavior include more adequate and timely remuneration within the public sector, educating patient populations of free or low‐cost services, and evidence‐based methods to increase provider motivation.

“When it comes to time of removal, nothing is straightforward”: A qualitative study of experiences with barriers to removal of long-acting reversible contraception in Western Kenya

“…However, providers may be capable but refuse for other reasons. Recent in-depth interviews with Kenyan providers found some refused to remove implants without extra compensation due to the difficulty of the procedure [22] . Research in other contexts indicates that providers may be reluctant to perform LARC removals because of concerns about unintended pregnancy, believing women will like the method if they can endure initial side effects [ 23 , 24 ].…”

Free Access to a Broad Contraceptive Method Mix and Women's Contraceptive Choice: Evidence from Sub‐Saharan Africa

“…These findings suggest that removing user fees alone might not have a transformative impact on contraceptive uptake. In particular, women from underserved communities might not be aware of the availability of free family planning services even when they are offered for free (Tumlinson, Gichane, and Curtis 2020). For this reason, family planning promotion programs, such as the Special Family Planning Days programs that provide free contraceptive services in East Africa, often select high volume locations in the community, such as market places, and conduct community mobilization through community health workers to inform women about upcoming service schedules (High Impact Practices in Family Planning 2019).…”

The hidden financial burden of healthcare: a systematic literature review of informal payments in Sub-Saharan Africa

“…Mostly, healthcare workers rather than the patients initiated informal payments 13,31,32,43,51 . Patients paid informally, before care, mainly to access drugs and services, many of which should have been provided for free [32][33][34]42,48,51 . Some patients also made informal payments after service delivery as gifts to express gratitude 42,50 .…”

“…The studies were conducted with a diverse group of participants with the majority being healthcare workers, patients, and households. Most studies assessed informal payments for health services in general while seven studies looked at informal payments for specific services, that is, maternal and child health services [32][33][34][35] , emergency services 50 , malaria treatment 36 , and HIV services 37 .…”

“…Patients or their relatives made informal payments for treatment to be initiated 32,50 , to receive both minor services such as bedpans 42 , injections 51 , or vaccinations 33 ; and major services, such as surgeries 32,42 . Informal payments were also made to receive drugs that were supposed to be provided for free [32][33][34]42,44,48,51 , and to obtain medical record books and reports 48 . In Tanzania, some healthcare providers feigned stockouts of commodities and sought money from patients disguising to purchase the commodities from the private market on their behalf 42 .…”