Extending coverage to informal sector populations in Kenya: design preferences and implications for financing policy.

BACKGROUND: Universal health coverage (UHC) is important in terms of improving access to quality health care while protecting households from the risk of catastrophic health spending and impoverishment. However, progress to UHC has been hampered by the measures to increase mandatory prepaid funds especially in low- and middle-income countries where there are large populations in the informal sector. Important considerations in expanding coverage to the informal sector should include an exploration of the type of prepayment system that is acceptable to the informal sector and the features of such a design that would encourage prepayment for health care among this population group. The objective of the study was to document the views of informal sector workers regarding different prepayment mechanisms, and critically analyze key design features of a future health system and the policy implications of financing UHC in Kenya. METHODS: This was part of larger study which involved a mixed-methods approach. The following tools were used to collect data from informal sector workers: focus group discussions [N = 16 (rural = 7; urban = 9)], individual in-depth interviews [N = 26 (rural = 14; urban = 12)] and a questionnaire survey [N = 455(rural = 129; urban = 326)]. Thematic approach was used to analyze qualitative data while Stata v.11 involving mainly descriptive analysis was used in quantitative data. The tools mentioned were used to collect data to meet various objectives of a larger study and what is presented here constitutes a small section of the data generated by these tools. RESULTS: The findings show that informal sector workers in rural and urban areas prefer different prepayment systems for financing UHC. Preference for a non-contributory system of financing UHC was particularly strong in the urban study site (58%). Over 70% in the rural area preferred a contributory mechanism in financing UHC. The main concern for informal sector workers regardless of the overall design of the financing approach to UHC included a poor governance culture especially one that does not punish corruption. Other reasons especially with regard to the contributory financing approach included high premium costs and inability to enforce contributions from informal sector. CONCLUSION: On average 47% of all study participants, the largest single majority, are in favor of a non-contributory financing mechanism. Strong evidence from existing literature indicates difficulties in implementing social contributions as the primary financing mechanism for UHC in contexts with large informal sector populations. Non-contributory financing should be strongly recommended to policymakers to be the primary financing mechanism and supplemented by social contributions.

The cost of free health care for all Kenyans: assessing the financial sustainability of contributory and non-contributory financing mechanisms.

BACKGROUND: The need to provide quality and equitable health services and protect populations from impoverishing health care costs has pushed universal health coverage (UHC) to the top of global health policy agenda. In many developing countries where the majority of the population works in the informal sector, there are critical debates over the best financing mechanisms to progress towards UHC. In Kenya, government health policy has prioritized contributory financing strategy (social health insurance) as the main financing mechanism for UHC. However, there are currently no studies that have assessed the cost of either social health insurance (SHI) as the contributory approach or an alternative financing mechanism involving non-contributory (general tax funding) approaches to UHC in Kenya. The aim of this study was to critically assess the financial requirements of both contributory and non-contributory mechanisms to financing UHC in Kenya in the context of large informal sector populations. METHODS: SimIns Basic® model, Version 2.1, 2008 (WHO/GTZ), was used to assess the feasibility of UHC in Kenya and provide estimates of financial resource needs for UHC over a 17-year period (2013-2030). Data sources included review of national and international literature on inflation, demography, macro-economy, health insurance, health services unit costs and utilization rates. The data were triangulated across geographic regions for accuracy and integrity of the simulation. SimIns models for 10 years only so data from the final year of the model was used to project for another 7 years. The 17-year period was necessary because the Government of Kenya aims to achieve UHC by 2030. RESULTS AND CONCLUSIONS: The results show that SHI is financially sustainable (Sustainability in this study is used to mean that expenditure does not outstrip revenue.) (revenues and expenditure match) within the first five years of implementation, but it becomes less sustainable with time. Modelling for a non-contributory scenario, on the other hand, showed greater sustainability both in the short- and long-term. The financial resource requirements for universal access to health care through general government revenue are compared with a contributory health insurance scheme approach. Although both funding options would require considerable government subsidies, given the magnitude of the informal sector in Kenya and their limited financial capacity, a tax-funded system would be less costly and more sustainable in the long-term than an insurance scheme approach. However, more innovative financing for health care as well as giving the health sector higher priority in government expenditure will be required to make the non-contributory financing mechanism more sustainable.

" still waiting for chloroquine": the challenge of communicating changes in first-line treatment policy for uncomplicated malaria in a remote Kenyan district.

BACKGROUND: Widespread parasite resistance to first-line treatment for uncomplicated malaria leads to introduction of new drug interventions. Introducing such interventions is complex and sensitive because of stakeholder interests and public resistance. To enhance take up of such interventions, health policy communication strategies need to deliver accurate and accessible information to empower communities with necessary information and address problems of cultural acceptance of new interventions. OBJECTIVES: To explore community understanding of policy changes in first-line treatment for uncomplicated malaria in Kenya; to evaluate the potential role of policy communication in influencing responses to changes in first-line treatment policy. METHODS: Data collection involved qualitative strategies in a remote district in the Kenyan Coast: in-depth interviews (n = 29), focus group discussions (n = 14), informal conversations (n = 11) and patient narratives (n = 8). Constant comparative method was used in the analysis. Being malaria-prone and remotely located, the district offered an ideal area to investigate whether or not and how policy communication about a matter as critical as change of treatment policy reaches vulnerable populations. RESULTS: Three years after initial implementation (2009), there was limited knowledge or understanding regarding change of first-line treatment from sulphadoxine-pyrimethamine (SP) to artemether-lumefantrine (AL) for treatment of uncomplicated malaria in the study district. The print and electronic media used to create awareness about the drug change appeared to have had little impact. Although respondents were aware of the existence of AL, the drug was known neither by name nor as the official first-line treatment. Depending on individuals or groups, AL was largely viewed negatively. The weaknesses in communication strategy surrounding the change to AL included poor choice of communication tools, confusing advertisements of other drugs and conflicts between patients and providers. CONCLUSION: Effective health policy communication is important for the uptake of new drug interventions and adherence to treatment regimens. Besides, prompt access to effective treatment may not be achieved if beneficiaries are not adequately informed about treatment policy changes. Future changes in treatment policy should ensure that the communication strategy is designed to pass sustained, accurate and effective messages that account for local contexts.

Viewing the Kenyan health system through an equity lens: implications for universal coverage.

INTRODUCTION: Equity and universal coverage currently dominate policy debates worldwide. Health financing approaches are central to universal coverage. The way funds are collected, pooled, and used to purchase or provide services should be carefully considered to ensure that population needs are addressed under a universal health system. The aim of this paper is to assess the extent to which the Kenyan health financing system meets the key requirements for universal coverage, including income and risk cross-subsidisation. Recommendations on how to address existing equity challenges and progress towards universal coverage are made. METHODS: An extensive review of published and gray literature was conducted to identify the sources of health care funds in Kenya. Documents were mainly sourced from the Ministry of Medical Services and the Ministry of Public Health and Sanitation. Country level documents were the main sources of data. In cases where data were not available at the country level, they were sought from the World Health Organisation website. Each financing mechanism was analysed in respect to key functions namely, revenue generation, pooling and purchasing. RESULTS: The Kenyan health sector relies heavily on out-of-pocket payments. Government funds are mainly allocated through historical incremental approach. The sector is largely underfunded and health care contributions are regressive (i.e. the poor contribute a larger proportion of their income to health care than the rich). Health financing in Kenya is fragmented and there is very limited risk and income cross-subsidisation. The country has made little progress towards achieving international benchmarks including the Abuja target of allocating 15% of government's budget to the health sector. CONCLUSIONS: The Kenyan health system is highly inequitable and policies aimed at promoting equity and addressing the needs of the poor and vulnerable have not been successful. Some progress has been made towards addressing equity challenges, but universal coverage will not be achieved unless the country adopts a systemic approach to health financing reforms. Such an approach should be informed by the wider health system goals of equity and efficiency.

Barriers to prompt and effective malaria treatment among the poorest population in Kenya.

BACKGROUND: Prompt access to effective malaria treatment is central to the success of malaria control worldwide, but few fevers are treated with effective anti-malarials within 24 hours of symptoms onset. The last two decades saw an upsurge of initiatives to improve access to effective malaria treatment in many parts of sub-Saharan Africa. Evidence suggests that the poorest populations remain least likely to seek prompt and effective treatment, but the factors that prevent them from accessing interventions are not well understood. With plans under way to subsidize ACT heavily in Kenya and other parts of Africa, there is urgent need to identify policy actions to promote access among the poor. This paper explores access barriers to effective malaria treatment among the poorest population in four malaria endemic districts in Kenya. METHODS: The study was conducted in the poorest areas of four malaria endemic districts in Kenya. Multiple data collection methods were applied including: a cross-sectional survey (n=708 households); 24 focus group discussions; semi-structured interviews with health workers (n=34); and patient exit interviews (n=359). RESULTS: Multiple factors related to affordability, acceptability and availability interact to influence access to prompt and effective treatment. Regarding affordability, about 40 percent of individuals who self-treated using shop-bought drugs and 42 percent who visited a formal health facility reported not having enough money to pay for treatment, and having to adopt coping strategies including borrowing money and getting treatment on credit in order to access care. Other factors influencing affordability were seasonality of illness and income sources, transport costs, and unofficial payments. Regarding acceptability, the major interrelated factors identified were provider patient relationship, patient expectations, beliefs on illness causation, perceived effectiveness of treatment, distrust in the quality of care and poor adherence to treatment regimes. Availability barriers identified were related to facility opening hours, organization of health care services, drug and staff shortages. CONCLUSIONS: Ensuring that all individuals suffering from malaria have prompt access to effective treatment remains a challenge for resource constrained health systems. Policy actions to address the multiple barriers of access should be designed around access dimensions, and should include broad interventions to revitalize the public health care system. Unless additional efforts are directed towards addressing access barriers among the poor and vulnerable, malaria will remain a major cause of morbidity and mortality in sub-Saharan Africa.

The economic costs of malaria in four Kenyan districts: do household costs differ by disease endemicity?

BACKGROUND: Malaria inflicts significant costs on households and on the economy of malaria endemic countries. There is also evidence that the economic burden is higher among the poorest in a population, and that cost burdens differ significantly between wet and dry seasons. What is not clear is whether, and how, the economic burden of malaria differs by disease endemicity. The need to account for geographical and epidemiological differences in the estimation of the social and economic burden of malaria is well recognized, but there is limited data, if any, to support this argument. This study sought to contribute towards filling this gap by comparing malaria cost burdens in four Kenyan districts of different endemicity. METHODS: A cross-sectional household survey was conducted during the peak malaria transmission season in the poorest areas in four Kenyan districts with differing malaria transmission patterns (n = 179 households in Bondo; 205 Gucha; 184 Kwale; 141 Makueni). FINDINGS: There were significant differences in duration of fever, perception of fever severity and cost burdens. Fever episodes among adults and children over five years in Gucha and Makueni districts (highland endemic and low acute transmission districts respectively) lasted significantly longer than episodes reported in Bondo and Kwale districts (high perennial transmission and seasonal, intense transmission, respectively). Perceptions of illness severity also differed between districts: fevers reported among older children and adults in Gucha and Makueni districts were reported as severe compared to those reported in the other districts. Indirect and total costs differed significantly between districts but differences in direct costs were not significant. Total household costs were highest in Makueni (US$ 19.6 per month) and lowest in Bondo (US$ 9.2 per month). CONCLUSIONS: Cost burdens are the product of complex relationships between social, economic and epidemiological factors. The cost data presented in this study reflect transmission patterns in the four districts, suggesting that a relationship between costs burdens and the nature of transmission might exist, and that the same warrants more attention from researchers and policy makers.

Towards achieving Abuja targets: identifying and addressing barriers to access and use of insecticides treated nets among the poorest populations in Kenya.

BACKGROUND: Ensuring that the poor and vulnerable population benefit from malaria control interventions remains a challenge for malaria endemic countries. Until recently, ownership and use of insecticides treated nets (ITNs) in most countries was low and inequitable, although coverage has increased in countries where free ITN distribution is integrated into mass vaccination campaigns. In Kenya, free ITNs were distributed to children aged below five years in 2006 through two mass campaigns. High and equitable coverage were reported after the campaigns in some districts, although national level coverage remained low, suggesting that understanding barriers to access remains important. This study was conducted to explore barriers to ownership and use of ITNs among the poorest populations before and after the mass campaigns, to identify strategies for improving coverage, and to make recommendations on how increased coverage levels can be sustained. METHODS: The study was conducted in the poorest areas of four malaria endemic districts in Kenya. Multiple data collection methods were applied including: cross-sectional surveys (n = 708 households), 24 focus group discussions and semi-structured interviews with 70 ITN suppliers. RESULTS: Affordability was reported as a major barrier to access but non-financial barriers were also shown to be important determinants. On the demand side key barriers to access included: mismatch between the types of ITNs supplied through interventions and community preferences; perceptions and beliefs on illness causes; physical location of suppliers and; distrust in free delivery and in the distribution agencies. Key barriers on the supply side included: distance from manufacturers; limited acceptability of ITNs provided through interventions; crowding out of the commercial sector and the price. Infrastructure, information and communication played a central role in promoting or hindering access. CONCLUSIONS: Significant resources have been directed towards addressing affordability barriers through providing free ITNs to vulnerable groups, but the success of these interventions depends largely on the degree to which other barriers to access are addressed. Only if additional efforts are directed towards addressing non-financial barriers to access, will high coverage levels be achieved and sustained.

Reducing user fees for primary health care in Kenya: Policy on paper or policy in practice?

BACKGROUND: Removing user fees in primary health care services is one of the most critical policy issues being considered in Africa. User fees were introduced in many African countries during the 1980s and their impacts are well documented. Concerns regarding the negative impacts of user fees have led to a recent shift in health financing debates in Africa. Kenya is one of the countries that have implemented a user fees reduction policy. Like in many other settings, the new policy was evaluated less that one year after implementation, the period when expected positive impacts are likely to be highest. This early evaluation showed that the policy was widely implemented, that levels of utilization increased and that it was popular among patients. Whether or not the positive impacts of user fees removal policies are sustained has hardly been explored. We conducted this study to document the extent to which primary health care facilities in Kenya continue to adhere to a 'new' charging policy 3 years after its implementation. METHODS: Data were collected in two districts (Kwale and Makueni). Multiple methods of data collection were applied including a cross-sectional survey (n = 184 households Kwale; 141 Makueni), Focus Group Discussions (n = 12) and patient exit interviews (n = 175 Kwale; 184 Makueni). RESULTS: Approximately one third of the survey respondents could not correctly state the recommended charges for dispensaries, while half did not know what the official charges for health centres were. Adherence to the policy was poor in both districts, but facilities in Makueni were more likely to adhere than those in Kwale. Only 4 facilities in Kwale adhered to the policy compared to 10 in Makueni. Drug shortage, declining revenue, poor policy design and implementation processes were the main reasons given for poor adherence to the policy. CONCLUSION: We conclude that reducing user fees in primary health care in Kenya is a policy on paper that is yet to be implemented fully. We recommend that caution be taken when deciding on how to reduce or abolish user fees and that all potential consequences are carefully considered.

Does the Informal Sector in Kenya Have Financial Potential to Sustainably Prepay for Health Care? Implications for Financing Universal Health Coverage in Low-Income Settings.

Kenya currently lacks evidence on whether income in the informal sector is sustainable and predictable and therefore able to support financing of universal health coverage (UHC). This article demonstrates the financial potential of informal sector entities to sustainably finance UHC in Kenya. Data were collected using a standardized questionnaire on the following topics: nature and sustainability of informal sector entities, indicators of financial potential, and socioeconomic status. Both descriptive and multivariate analyses were used. The findings indicate that income in the informal sector is generally low although investors in health/medical, stationery, entertainment, manufacturing and craft as well as transportation tend to have higher and more consistent incomes than most others in both sites. Mean monthly incomes ranged from 16.7 USD (lowest) to 786.5 USD (highest). The urban informal sector recorded higher mean monthly incomes of 195.8 USD compared to 77.9 USD in the rural area (P < 0.001). The most sustainable entities in the urban area included stationery (67%), repair and maintenance (50%), food vending (49%), shopkeeping (48%), and clothing and beauty products (43%). Farming (90%), manufacturing and craft (86%), and health/medical (100%) were the most sustainable in the rural area. Key predictors of sustainable informal sector entities include monthly expenditure patterns, gender, marital status, household structure, number of employees in an entity, and land ownership in the rural area and number of entities owned. Informal sector entities are mostly unsustainable, meaning that the majority of premium contributors will not be consistent in payment and will likely to require subsidies.

Medicine Prices, Availability, and Affordability in Private Health Facilities in Low-Income Settlements in Nairobi County, Kenya.

Medicine prices are a major determinant of access to healthcare. Owing to low availability of medicines in the public health facilities and poor accessibility to these facilities, most low-income residents pay out-of-pocket for health services and transport to the private health facilities. In low-income settlements, high retail prices are likely to push the population further into poverty and ill health. This study assessed the retail pricing, availability, and affordability of medicines in private health facilities in low-income settlements within Nairobi County. Medicine prices and availability data were collected between September and December 2016 at 45 private healthcare facilities in 14 of Nairobi's low-income settlements using electronic questionnaires. The International Medical Products Price Guide provided international medicine reference prices for comparison. Affordability and availability proxies were calculated according to existing methods. Innovator brands were 13.8 times more expensive than generic brands. The lowest priced generics and innovator brands were, on average, sold at 2.9 and 32.6 times the median international reference prices of corresponding medicines. Assuming a 100% disposable income, it would take 0.03 to 1.33 days' wages for the lowest paid government employee to pay for treatment courses of selected single generic medicines. Medicine availability in the facilities ranged between 2% and 76% (mean 43%) for indicator medicines. Prices of selected medicines varied within the 14 study regions. Retail medicine prices in the low-income settlements studied were generally higher than corresponding international reference prices. Price variations were observed across different regions although the regions comprise similar socioeconomic populations. These factors are likely to impact negatively on healthcare access.