title: Influence of health-insurance access and hospital retention policies on childhood cancer treatment in Kenya.
abstract: BACKGROUND
  Kenyan national policies for public hospitals dictate that patients are retained on hospital wards until their hospital bills are paid, but this payment process differs for patients with or without access to National Hospital Insurance Fund (NHIF) at diagnosis. Whether these differences impact treatment outcomes has not been described. Our study explores whether childhood cancer treatment outcomes in Kenya are influenced by health-insurance status and hospital retention policies.
  
  
  METHODS
  This study combined retrospective review of medical records with an illustrative case report. We identified children diagnosed with malignancies at a large Kenyan academic hospital between 2007 and 2009, their treatment outcomes, and health-insurance status at diagnosis.
  
  
  RESULTS
  Between 2007 and 2009, 222 children were diagnosed with malignancies. Among 180 patients with documented treatment outcome, 54% abandoned treatment, 22% had treatment-related death, 4% progressive/relapsed disease, and 19% event-free survival. Health-insurance status at diagnosis was recorded in 148 children: 23% had NHIF and 77% had no NHIF. For children whose families had NHIF compared with those who did not, the relative risk for treatment abandonment relative to event-free survival was significantly smaller (relative-risk ratio = 0.31, 95% CI = 0.12-0.81, P = 0.016). The case report illustrates difficulties that Kenyan families might face when their child is diagnosed with cancer, has no NHIF, and is retained in hospital.
  
  
  CONCLUSIONS
  Children with NHIF at diagnosis had significantly lower chance of abandoning treatment and higher chance of survival. Childhood cancer treatment outcomes could be improved by interventions that prevent treatment abandonment and improve access to NHIF. Hospital retention of patients over unpaid medical bills must stop.
authors.affiliation: Department of Pediatric Oncology-Hematology and Doctor 2 Doctor Program, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: S
authors.initials: S
authors.lastname: Mostert
authors.forename: F
authors.initials: F
authors.lastname: Njuguna
authors.forename: P M
authors.initials: PM
authors.lastname: van de Ven
authors.forename: G
authors.initials: G
authors.lastname: Olbara
authors.forename: L J P A
authors.initials: LJ
authors.lastname: Kemps
authors.forename: J
authors.initials: J
authors.lastname: Musimbi
authors.forename: R M
authors.initials: RM
authors.lastname: Strother
authors.forename: L M
authors.initials: LM
authors.lastname: Aluoch
authors.forename: J
authors.initials: J
authors.lastname: Skiles
authors.forename: N G
authors.initials: NG
authors.lastname: Buziba
authors.forename: M N
authors.initials: MN
authors.lastname: Sitaresmi
authors.forename: R C
authors.initials: RC
authors.lastname: Vreeman
authors.forename: G J L
authors.initials: GJ
authors.lastname: Kaspers
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002662:Child Health Services / Q000191:economics / Q000706:statistics & numerical data*; D002675:Child, Preschool; D003906:Developing Countries; D005260:Female; D005500:Follow-Up Studies; D006297:Health Services Accessibility; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007348:Insurance, Health; D007630:Kenya; D007882:Legislation, Hospital / Q000191:economics*; D008297:Male; D008499:Medical Records; D009369:Neoplasms / Q000175:diagnosis / Q000191:economics / Q000628:therapy*; D016017:Odds Ratio; D011379:Prognosis; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D015996:Survival Rate; D055815:Young Adult
keywords: adherence; childhood cancer; health-insurance; hospital retention; low-income countries