Implementation of patient charges at primary care facilities in Kenya: implications of low adherence to user fee policy for users and facility revenue.
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.
Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya, Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Centre for Clinical Vaccinology and Tropical Medicine, Oxford OX3 7LJ, UK, MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK and Department for Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK.
Antony
A
Opwora
Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya, Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Centre for Clinical Vaccinology and Tropical Medicine, Oxford OX3 7LJ, UK, MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK and Department for Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK.
Evelyn
E
Waweru
Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya, Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Centre for Clinical Vaccinology and Tropical Medicine, Oxford OX3 7LJ, UK, MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK and Department for Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK.
Mitsuru
M
Toda
Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya, Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Centre for Clinical Vaccinology and Tropical Medicine, Oxford OX3 7LJ, UK, MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK and Department for Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya, Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Centre for Clinical Vaccinology and Tropical Medicine, Oxford OX3 7LJ, UK, MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK and Department for Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK.
Abdisalan
A
Noor
Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya, Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Centre for Clinical Vaccinology and Tropical Medicine, Oxford OX3 7LJ, UK, MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK and Department for Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK.
Tansy
T
Edwards
Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya, Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Centre for Clinical Vaccinology and Tropical Medicine, Oxford OX3 7LJ, UK, MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK and Department for Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya, Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Centre for Clinical Vaccinology and Tropical Medicine, Oxford OX3 7LJ, UK, MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK and Department for Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK.
Greg
G
Fegan
Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya, Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Centre for Clinical Vaccinology and Tropical Medicine, Oxford OX3 7LJ, UK, MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK and Department for Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya, Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Centre for Clinical Vaccinology and Tropical Medicine, Oxford OX3 7LJ, UK, MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK and Department for Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK.
Sassy
S
Molyneux
Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya, Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya, Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Centre for Clinical Vaccinology and Tropical Medicine, Oxford OX3 7LJ, UK, MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK and Department for Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK catherine.goodman@lshtm.ac.uk.
Catherine
C
Goodman
D000328:Adult; D002648:Child; D003906:Developing Countries; D018588:Fee-for-Service Plans / Q000191:economics* / Q000706:statistics & numerical data; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans; D007630:Kenya; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000191:economics* / Q000379:methods
Health-care financing; Kenya; primary health care; user fees