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Annual Evaluation of the Abolition of User Fees at Primary Healthcare Facilities in Kenya

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Annual Evaluation of the Abolition of User Fees at Primary Healthcare Facilities in Kenya September 2015 ANNUAL EVALUATION OF THE ABOLITION OF USER FEES AT PRIMARY HEALTHCARE FACILITIES IN KENYA This publication was prepared by Thomas Maina of the Health Policy Project and Doris Kirigia (independent consultant). HEALTH POLICY PROJECT Suggested citation: Maina, T. and D. Kirigia. 2015. Annual Evaluation of the Abolition of User Fees at Prim ary Healthcare Facilities in Kenya. W ashington, DC: Futures Group, Health Policy Project. ISBN: 978-1-59560-120-9 The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. The project’s HIV activities are supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). It is implemented by Futures Group, in collaboration with Plan International USA, Avenir Health (formerly Futures Institute), Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). Annual Evaluation of the Abolition of User Fees at Primary Healthcare Facilities in Kenya SEPTEMBER 2015 This publication was prepared by Thomas Maina of the Health Policy Project and Doris Kirigia (independent consultant). The information prov ided in this document is not official U.S. Gov ernment information and does not necessarily represent the views or positions of the U.S. Agency for International Development. CONTENTS List of Tables ............................................................................................................................. iv List of Figures............................................................................................................................ iv Executive Summary................................................................................................................. v Background .............................................................................................................................. v Results ..................................................................................................................................... v Conclusion and Recommendations ............................................................................................vii Abbreviations ......................................................................................................................... viii Background .............................................................................................................................. 1 Rationale of the Study ............................................................................................................... 2 Study Objectives ....................................................................................................................... 2 Methodology ............................................................................................................................ 3 Study Design ............................................................................................................................ 3 Data Collection Methods ........................................................................................................... 4 Data Management and Analysis ................................................................................................. 5 Survey Respondents .................................................................................................................. 5 Characteristics of Facility In-charges, Health Workers, and Clients/Patients Interviewed ............... 5 Results........................................................................................................................................ 8 Utilization Patterns Before and After Policy Change.................................................................... 8 Adherence to the Removal of User Fees Policy ......................................................................... 17 The Policy Implementation Process .......................................................................................... 18 Patients’ Perceptions of the Quality of Care Following the Removal of User Fees ....................... 20 Availability of Key Health Inputs: Basic Infrastructure, Medical Equipment, and Essential Medicines for Mothers and Children......................................................................................... 22 Health Workers’ Perceptions of the Removal of User Fees......................................................... 24 Discussion ............................................................................................................................... 27 Conclusion and Recommendations ................................................................................... 29 References.............................................................................................................................. 30 Appendix 1: Distribution of Facilities in the Study Sample ............................................... 31 iii LIST OF TABLES Table 1. Counties Included in the User Fees Removal Study............................................................ 4 Table 2. Data Sources and Range of Information Collected ............................................................. 5 Table 3. Numbers of Facilities and Respondents ............................................................................. 6 Table 4. Distribution of Facility In-charges Interviewed by Qualification and Facility Type and Ownership.................................................................................................................................... 6 Table 5. Distribution of Health Workers Interviewed by Qualification and Facility Type and Ownership.................................................................................................................................... 7 Table 6. Public Health Centers and Dispensaries Utilization ............................................................ 8 Table 7. Public Health Centers and Dispensaries Utilization of Immunization and ANC Services .... 11 Table 8. Utilization of ANC and Delivery Services in Public and FBO Facilities ............................ 13 Table 9. Payment Responses by Facility Type and Ownership ....................................................... 17 Table 10. Clients’ Perceptions of Changes in Healthcare After the Removal of User Fees ............... 20 Table 11. Clients’ Perceptions of Availability of Drugs and Other Medical Supplies ...................... 21 Table 12. Issues Mentioned by Health Workers About Fee Removal That Has Changed Their and Their Patients’ Situat ions ........................................................................................................... 24 Table 13: Has removal of user fees at public lower-level facilities increased the number of patients/clients seen by providers each day? ................................................................................. 25 Table 14: Dimensions of the Impact of Free Healthcare on the Working Conditions of Health Workers ..................................................................................................................................... 26 LIST OF FIGURES Figure 1. Outpatient Utilization, Under Age Five (first visit and re-attendance)................................. 9 Figure 2. Outpatient Utilization for Population over Age Five (first visit and re-attendance) ............ 10 Figure 3. Fully Immunized Children ............................................................................................ 12 Figure 4. Number Routine and Special Laboratory Test................................................................. 13 Figure 5. Number of Pregnant Women Making First ANC Visit .................................................... 14 Figure 6. Number of Pregnant Women Making >= 4 Visits ........................................................... 15 Figure 7. Total Number of Deliveries in Health Centers and Dispensaries ...................................... 16 Figure 8. Utilization of Outpatient Services by Socioeconomic Category........................................ 17 Figure 9. Availability of Priority Medicine for Children ................................................................ 22 Figure 10. Priority Medicine for Mothers ..................................................................................... 23 Figure 11. Infrastructure and Medical Equipment Availability, by Facility Ownership .................... 24 iv EXECUTIVE SUMMARY Background Abolition of user fees in primary healthcare facilities is now widely considered by developing countries as one of the key policy options to address access to healthcare services by the poor and vulnerable. User fees, introduced in Kenya and many other low-income countries in the late 1980s, have failed to achieve the intended objective of improving access to healthcare. Instead, user fees have imposed a barrier to accessing health services by the poor and vulnerable and have contributed to inequalities in access to healthcare. In response, many African countries introduced partial or total elimination of user fees in the 2000s (Meessen et al., 2011). In 2004, Kenya followed suit, removing all user fees at public dispensaries and health centers, except for a minimum registration fee of 10 or 20 Kenya shillings (KShs). 1 Commonly referred to as the 10/20 policy, children under age
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