Implementation of patient charges at primary care facilities in Kenya: implications of low adherence to user fee policy for users and facility revenue

Abstract

With user fees now seen as a major hindrance to universal health coverage, many countries have introduced fee reduction or elimination policies, but there is growing evidence that adherence to reduced fees is often highly imperfect. In 2004, Kenya adopted a reduced and uniform user fee policy providing fee exemptions to many groups. We present data on user fee implementation, revenue and expenditure from a nationally representative survey of Kenyan primary health facilities. Data were collected from 248 randomly selected public health centres and dispensaries in 2010, comprising an interview with the health worker in charge, exit interviews with curative outpatients, and a financial record review. Adherence to user fee policy was assessed for eight tracer conditions based on health worker reports, and patients were asked about actual amounts paid. No facilities adhered fully to the user fee policy across all eight tracers, with adherence ranging from 62.2% for an adult with tuberculosis to 4.2% for an adult with malaria. Three quarters of exit interviewees had paid some fees, with a median payment of US dollars (USD) 0.39, and a quarter of interviewees were required to purchase additional medical supplies at a later stage from a private drug retailer. No consistent pattern of association was identified between facility characteristics and policy adherence. User fee revenues accounted for almost all facility cash income, with average revenue of USD 683 per facility per year. Fee revenue was mainly used to cover support staff, non-drug supplies and travel allowances. Adherence to user fee policy was very low, leading to concerns about the impact on access and the financial burden on households. However, the potential to ensure adherence was constrained by the facilities’ need for revenue to cover basic operating costs, highlighting the need for alternative funding strategies for peripheral health facilities.

Patient costs of diabetes mellitus care in public health care facilities in Kenya

“…Costs due to medicine have been shown to reduce adherence to medication and demand for health services by patients with NCDs . Past studies conducted in LMICs have however shown that social health insurance schemes do not comprehensively cover the costs for medicines and that OOP costs, which are majorly contributed by medicines, are a hindrance to attainment of universal health coverage in many low resource settings . Indeed, any reductions or removal of medicine costs is likely to increase access to DM health care services, but additional resources will be required to cover any concomitant increase in service utilization.…”

Perceived Quality of Care of Community Health Worker and Facility-Based Health Worker Management of Pneumonia in Children Under 5 Years in Western Kenya: A Cross-Sectional Multidimensional Study

“…34,35 Though Kenya has implemented a policy to decrease user fees, 36 especially for the poorest Kenyans, there is a lack of adherence to this policy. 37 And there are still many indirect costs associated with seeking care from a health facility such as the cost of transportation, food, and foregone work. 35 Home case management by well-trained well-supplied CHWs may be one way to expand access to care to this population.…”

Sampling for Patient Exit Interviews: Assessment of Methods Using Mathematical Derivation and Computer Simulations

“…; Opwora et al. ), health care utilization (The Demographic and Health Surveys Program ; Etiaba et al. ), provider behavior during the clinical consultation (Stange et al.…”

“…, patients' out-of-pocket expenditures (Peabody et al 2010;Chimbindi et al 2015;Opwora et al 2015), health care utilization (The Demographic and Health Surveys Program 2015;Etiaba et al 2015), provider behavior during the clinical consultation (Stange et al 1998;Ostroff, Li, and Shelley 2014), and patients' knowledge about their condition (Senarath et al 2007;Anya, Hydara, and Jaiteh 2008;Israel-Ballard, Waithaka, and Greiner 2014). A number of standardized patient exit questionnaires have been developed for use by researchers, including the EUROPEP instrument (Wensing 2006), the RAND Patient Satisfaction Questionnaire (RAND Health 2015), the Patient Experiences Questionnaire (Steine, Finset, and Laerum 2001), and the patient exit questionnaires that form part of the Demographic and Health Surveys (DHS) Program's Service Provision Assessments (The Demographic and Health Surveys Program 2015).…”