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Wang H, Zeng W, Kabubei KM, Rasanathan JJK, Kazungu J, Ginindza S, Mtshali S, Salinas LE, McClelland A, Buissonniere M, Lee CT, Chuma J, Veillard J, Matsebula T, Chopra M. Modelling the economic burden of SARS-CoV-2 infection in health care workers in four countries. Nat Commun 2023; 14:2791. [PMID: 37188709 DOI: 10.1038/s41467-023-38477-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/03/2023] [Indexed: 05/17/2023] Open
Abstract
Health care workers (HCWs) experienced greater risk of SARS-CoV-2 infection during the COVID-19 pandemic. This study applies a cost-of-illness (COI) approach to model the economic burden associated with SARS-CoV-2 infections among HCWs in five low- and middle-income sites (Kenya, Eswatini, Colombia, KwaZulu-Natal province, and Western Cape province of South Africa) during the first year of the pandemic. We find that not only did HCWs have a higher incidence of COVID-19 than the general population, but in all sites except Colombia, viral transmission from infected HCWs to close contacts resulted in substantial secondary SARS-CoV-2 infection and death. Disruption in health services as a result of HCW illness affected maternal and child deaths dramatically. Total economic losses attributable to SARS-CoV-2 infection among HCWs as a share of total health expenditure ranged from 1.51% in Colombia to 8.38% in Western Cape province, South Africa. This economic burden to society highlights the importance of adequate infection prevention and control measures to minimize the risk of SARS-CoV-2 infection in HCWs.
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Affiliation(s)
| | - Wu Zeng
- Department of Global Health, Georgetown University, Washington, DC, USA.
| | | | | | - Jacob Kazungu
- Health Economics Research Unit, KEMRI Welcome Trust Research Program, Nairobi, Kenya
| | | | - Sifiso Mtshali
- Public Health Medicine Department, University of KwaZulu-Natal, Durban, South Africa
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Zeng W, Musiega A, Oyasi J, Giorgio LD, Chuma J, Lu R, Ahn H. Understanding the Performance of County Health Service Delivery in Kenya: A Mixed Method Analysis. Health Policy Plan 2021; 37:189-199. [PMID: 34718555 PMCID: PMC7613432 DOI: 10.1093/heapol/czab129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 10/08/2021] [Accepted: 10/22/2021] [Indexed: 11/14/2022] Open
Abstract
To better understand the wide variation of performance among county health systems in Kenya, this study investigated their performance determinants. We selected five counties with varied performance and examined their performance across five domains containing 10 thematic areas. We conducted a stakeholder analysis, consisting of focus group discussions and key informant interviews, and administered a quantitative survey to quantify the magnitude of inefficiency. The study found that a shortage of funding was one of the most common complaints from counties, leading to inefficiency in the health system. Another major reason for inefficiencies was the delay in disbursing funding to health facilities, which affected the procurement of medical supplies and commodities essential for delivering healthcare to the population. In addition, lack of autonomy in procuring commodities and equipment was repeatedly mentioned as a barrier to delivering quality health services. Other reported common concerns contributing to the performance of county health systems were the lack of lab tests and equipment, low willingness to join health insurance, rigid procurement policies and lengthy procurement process, lack of motivation and incentives for service delivery, and poor economic status. Despite the common concerns among the five counties, they differed in some schematic areas, such as the county’s commitment to health and community mobilization. In summary, this study suggests various factors that determine county health system performance. Given the multifaceted nature of inefficiency drivers, it is necessary to adopt a holistic approach to address the causes of inefficiencies and improve the county health systems
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Affiliation(s)
- Wu Zeng
- Department of International Health, School of Nursing & Health Studies, Georgetown University, 20007 USA
| | - Anita Musiega
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | | | | | - Ruoyan Lu
- School of Public Health, Fujian Medical University, China
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Moses MW, Korir J, Zeng W, Musiega A, Oyasi J, Lu R, Chuma J, Di Giorgio L. Performance assessment of the county healthcare systems in Kenya: a mixed-methods analysis. BMJ Glob Health 2021; 6:e004707. [PMID: 34167962 PMCID: PMC8230973 DOI: 10.1136/bmjgh-2020-004707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION A well performing public healthcare system is necessary for Kenya to continue progress towards universal health coverage (UHC). Identifying actionable measures to improve the performance of the public healthcare system is critical to progress towards UHC. We aimed to measure and compare the performance of Kenya's public healthcare system at the county level and explore remediable drivers of poor healthcare system performance. METHODS Using administrative data from fiscal year 2014/2015 through fiscal year 2017/2018, we measured the technical efficiency of 47 county-level public healthcare systems in Kenya using stochastic frontier analysis. We then regressed the technical efficiency measure against a set of explanatory variables to examine drivers of efficiency. Additionally, in selected counties, we analysed surveys and focus group discussions to qualitatively understand factors affecting performance. RESULTS The median technical efficiency of county public healthcare systems was 84% in fiscal year 2017/2018 (with an IQR of 79% to 90%). Across the four fiscal years of data, 27 out of the 47 Kenyan counties had a declining technical efficiency score. Our regression analysis indicated that impediments to the flow of funding-measured by the budget absorption rate which is the ratio between funds spent and funds released-were significantly related to poor healthcare system performance. Our analysis of interviews and surveys yielded a similar conclusion as nearly 50% of respondents indicated issues stemming from poor budget absorption were significant drivers of poor healthcare system performance. CONCLUSION Public healthcare systems at the county-level in Kenya general performed well; however, addressing delays in the flow of funding is a concrete step to improve healthcare system performance. As Kenya-and other countries-provides additional funding to meet their UHC goals, establishing a strong and robust public financial management system is critical to ensure that the benefits of UHC are realised.
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Affiliation(s)
| | - Julius Korir
- School of Economics, Kenyatta University, Nairobi, Kenya
| | - Wu Zeng
- Department of International Health, School of Nursing & Health Studies, Georgetown University, Washington, DC, USA
| | - Anita Musiega
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Ruoyan Lu
- School of Public Health, Fujian Medical University, Fujian, China
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Tsofa B, Musotsi P, Kagwanja N, Waithaka D, Molyneux S, Barasa E, Maina T, Chuma J. Examining health sector application and utility of program-based budgeting: County level experiences in Kenya. Int J Health Plann Manage 2021; 36:1521-1532. [PMID: 33955046 PMCID: PMC8519121 DOI: 10.1002/hpm.3174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 02/12/2021] [Accepted: 04/06/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction In 2012, Kenya enacted a new Public Finance Management Act to guide the public‐sector planning and budgeting process. This new law replaced the previous line item budgeting, with a new program‐based budgeting (PBB) process. This study examined the experience of health sector PBB implementation at the county level in Kenya. Methods We carried out a review of the literature documenting the health sector application and utility of PBB in low‐ and middle‐income countries. We then collected empirical data to examine the experience of health sector application of PBB at County Level in Kenya. Results In the financial year 2017/18, counties utilised the PBB approach for health sector planning. The PBB approach was perceived by key stakeholders; to have improved the alignment of technical priorities with budgetary allocation, and to have increased transparency, accountability and openness of the process. Its challenges included lack of clear tools and guidelines to support implementation, low capacity at county level, political interference and the organisation of the public sector electronic financial management system around line item budgeting system. Conclusion PBB is potentially a useful tool for aligning health sector planning and budgeting and ensuring the Annual Work Plan is more result oriented. However, realisation of this goal would be enhanced by the developing clear tools and guidelines to support its implementation, building capacity for county health sector managers to better understand the PBB application, and reforming the public‐sector budgetary management system to align it with the PBB approach.
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Affiliation(s)
- Benjamin Tsofa
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kenya.,Department of Public Health, School of Human and Health Sciences, Pwani University, Kenya
| | - Protus Musotsi
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kenya.,Department of Public Health, School of Human and Health Sciences, Pwani University, Kenya
| | - Nancy Kagwanja
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kenya
| | - Dennis Waithaka
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kenya
| | - Sassy Molyneux
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK
| | - Edwine Barasa
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kenya.,Department of Public Health, School of Human and Health Sciences, Pwani University, Kenya
| | - Thomas Maina
- The World Bank Group, Kenya Country Office, Kenya
| | - Jane Chuma
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kenya.,The World Bank Group, Kenya Country Office, Kenya
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Munywoki J, Kagwanja N, Chuma J, Nzinga J, Barasa E, Tsofa B. Tracking health sector priority setting processes and outcomes for human resources for health, five-years after political devolution: a county-level case study in Kenya. Int J Equity Health 2020; 19:165. [PMID: 32958000 PMCID: PMC7507677 DOI: 10.1186/s12939-020-01284-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 09/15/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Health sector priority setting in Low and Middle-Income Countries (LMICs) entails balancing between a high demand and low supply of scarce resources. Human Resources for Health (HRH) consume the largest allocation of health sector resources in LMICs. Health sector decentralization continues to be promoted for its perceived ability to improve efficiency, relevance and participation in health sector priority setting. Following the 2013 devolution in Kenya, both health service delivery and human resource management were decentralized to county level. Little is known about priority setting practices and outcomes of HRH within decentralized health systems in LMICs. Our study sought to examine if and how the Kenyan devolution has improved health sector priority setting practices and outcomes for HRH. METHODS We used a mixed methods case study design to examine health sector priority setting practices and outcomes at county level in Kenya. We used three sources of data. First, we reviewed all relevant national and county level policy and guidelines documents relating to HRH management. We then accessed and reviewed county records of HRH recruitment and distribution between 2013 and 2018. We finally conducted eight key informant interviews with various stakeholder involved in HRH priority setting within our study county. RESULTS We found that HRH numbers in the county increased by almost two-fold since devolution. The county had two forms of HRH recruitment: one led by the County Public Services Board as outlined by policy and guidelines and a parallel, politically-driven recruitment done directly by the County Department of Health. Though there were clear guidelines on HRH recruitment, there were no similar guidelines on allocation and distribution of HRH. Since devolution, the county has preferentially staffed higher level hospitals over primary care facilities. Additionally, there has been local county level innovations to address some HRH management challenges, including recruiting doctors and other highly specialized staff on fixed term contract as opposed to permanent basis; and implementation of local incentives to attract and retain HRH to remote areas within the county. CONCLUSION Devolution has significantly increased county level decision-space for HRH priority setting in Kenya. However, HRH management and accountability challenges still exist at the county level. There is need for interventions to strengthen county level HRH management capacity and accountability mechanisms beyond additional resources allocation. This will boost the realization of the country's efforts for promoting service delivery equity as a key goal - both for the devolution and the country's quest towards Universal Health Coverage (UHC).
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Affiliation(s)
- Joshua Munywoki
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya.
- Department of Public Health, School of Human and Health Sciences, Pwani University, Kilifi, Kenya.
| | - Nancy Kagwanja
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya
| | - Jane Chuma
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya
- The World Bank Group, Kenya Country Office, Nairobi, Kenya
| | - Jacinta Nzinga
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya
| | - Edwine Barasa
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya
| | - Benjamin Tsofa
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya.
- Department of Public Health, School of Human and Health Sciences, Pwani University, Kilifi, Kenya.
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Obadha M, Chuma J, Kazungu J, Abiiro GA, Beck MJ, Barasa E. Preferences of healthcare providers for capitation payment in Kenya: a discrete choice experiment. Health Policy Plan 2020; 35:842-854. [PMID: 32537642 PMCID: PMC7487334 DOI: 10.1093/heapol/czaa016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2020] [Indexed: 11/13/2022] Open
Abstract
Provider payment mechanisms (PPMs) are important to the universal health coverage (UHC) agenda as they can influence healthcare provider behaviour and create incentives for health service delivery, quality and efficiency. Therefore, when designing PPMs, it is important to consider providers' preferences for PPM characteristics. We set out to uncover senior health facility managers' preferences for the attributes of a capitation payment mechanism in Kenya. We use a discrete choice experiment and focus on four capitation attributes, namely, payment schedule, timeliness of payments, capitation rate per individual per year and services to be paid by the capitation rate. Using a Bayesian efficient experimental design, choice data were collected from 233 senior health facility managers across 98 health facilities in seven Kenyan counties. Panel mixed multinomial logit and latent class models were used in the analysis. We found that capitation arrangements with frequent payment schedules, timelier disbursements, higher payment rates per individual per year and those that paid for a limited set of health services were preferred. The capitation rate per individual per year was the most important attribute. Respondents were willing to accept an increase in the capitation rate to compensate for bundling a broader set of health services under the capitation payment. In addition, we found preference heterogeneity across respondents and latent classes. In conclusion, these attributes can be used as potential targets for interventions aimed at configuring capitation to achieve UHC.
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Affiliation(s)
- Melvin Obadha
- Health Economics Research Unit, KEMRI|Wellcome Trust Research Programme, P.O. Box 43640 – 00100, Nairobi, Kenya
| | - Jane Chuma
- Health Economics Research Unit, KEMRI|Wellcome Trust Research Programme, P.O. Box 43640 – 00100, Nairobi, Kenya
- The World Bank, Kenya Country Office, P.O. Box 30577-00100, Nairobi, Kenya
| | - Jacob Kazungu
- Health Economics Research Unit, KEMRI|Wellcome Trust Research Programme, P.O. Box 43640 – 00100, Nairobi, Kenya
| | - Gilbert Abotisem Abiiro
- Department of Planning, Faculty of Planning and Land Management, University for Development Studies, Wa, Ghana
| | - Matthew J Beck
- Institute of Transport and Logistics Studies, Business School, The University of Sydney, Darlington, New South Wales 2006, Australia
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI|Wellcome Trust Research Programme, P.O. Box 43640 – 00100, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Peter Medawar Building for Pathogen Research, South Parks Road, Oxford OX1 3SY, UK
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Ilinca S, Di Giorgio L, Salari P, Chuma J. Socio-economic inequality and inequity in use of health care services in Kenya: evidence from the fourth Kenya household health expenditure and utilization survey. Int J Equity Health 2019; 18:196. [PMID: 31849334 PMCID: PMC6918604 DOI: 10.1186/s12939-019-1106-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 12/09/2019] [Indexed: 11/27/2022] Open
Abstract
Background Kenya is experiencing persistently high levels of inequity in health and access to care services. In 2018, decades of sustained policy efforts to promote equitable, affordable and quality health services have culminated in the launch of a universal health coverage scheme, initially piloted in four Kenyan counties and planned for national rollout by 2022. Our study aims to contribute to monitoring and evaluation efforts alongside policy implementation, by establishing a detailed, baseline assessment of socio-economic inequality and inequity in health care utilization in Kenya shortly before the policy launch. Methods We use concentration curves and corrected concentration indexes to measure socio-economic inequality in care use and the horizontal inequity index as a measure of inequity in care utilization for three types of care services: outpatient care, inpatient care and preventive and promotive care. Further insights into the individual and household level characteristics that determine observed inequality are derived through decomposition analysis. Results We find significant inequality and inequity in the use of all types of care services favouring richer population groups, with particularly pronounced levels for preventive and inpatient care services. These are driven primarily by differences in living standards and educational achievement, while the region of residence is a key driver for inequality in preventive care use only. Pro-rich inequalities are particularly pronounced for care provided in privately owned facilities, while public providers serve a much larger share of individuals from lower socio-economic groups. Conclusions Through its focus on increasing affordability of care for all Kenyans, the newly launched universal health coverage scheme represents a crucial step towards reducing disparities in health care utilization. However in order to achieve equity in health and access to care such efforts must be paralleled by multi-sectoral approaches to address all key drivers of inequity: persistent poverty, disparities in living standards and educational achievement, as well as regional differences in availability and accessibility of care.
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Affiliation(s)
- Stefania Ilinca
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland. .,European Centre for Social Welfare Policy and Research, Vienna, Austria.
| | | | - Paola Salari
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
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Salari P, Di Giorgio L, Ilinca S, Chuma J. The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ Glob Health 2019. [PMID: 31803510 DOI: 10.1136/bmjgh‐2019‐001809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Introduction Progress towards effective service coverage and financial protection-the two dimensions of Universal Health Coverage (UHC)-has been limited in Kenya in the last decade. The government of Kenya has embarked on a highly ambitious reform programme currently being piloted in four Kenyan counties and aiming at national rollout by 2022. This study provides an updated assessment of the performance of the Kenyan health system in terms of financial protection allowing to monitor trends over time. In light of the UHC initiative, the study provides a baseline to assess the impact of the UHC pilot programme and inform scale-up plans. It also investigates household characteristics associated with catastrophic payments. Methods Using data from the Kenya Household Health Expenditure and Utilization Survey (KHHEUS) 2018, we investigated the incidence and intensity of catastrophic and impoverishing health expenditure. We used a logistic regression analysis to assess households' characteristics associated with the probability of incurring catastrophic health expenditures. Results The results show that the incidence of catastrophic payments is more severe for the poorest households and in the rural areas and mainly due to outpatient services. Results for the impoverishing effect suggest that after accounting for out-of-pocket(OOP) payments, the proportion of poor people increases by 2.2 percentage points in both rural and urban areas. Thus, between 1 and 1.1 million individuals are pushed into poverty due to OOP payments. Among the characteristics associated with the probability of incurring OOP expenditures, socioeconomic conditions, the presence of elderly and of people affected by chronic conditions showed significant results. Conclusion Kenya is still lagging behind in terms of protecting its citizens against financial risks associated with ill health and healthcare seeking behaviour. More effort is needed to protect the most vulnerable population groups from the high costs of illness.
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Affiliation(s)
- Paola Salari
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland.,Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | | | - Stefania Ilinca
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland.,European Centre for Social Welfare Policy and Research, Vienna, Austria
| | - Jane Chuma
- The World Bank, Kenya Country Office, Nairobi, Kenya
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Salari P, Di Giorgio L, Ilinca S, Chuma J. The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ Glob Health 2019; 4:e001809. [PMID: 31803510 PMCID: PMC6882550 DOI: 10.1136/bmjgh-2019-001809] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/27/2019] [Accepted: 11/02/2019] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Progress towards effective service coverage and financial protection-the two dimensions of Universal Health Coverage (UHC)-has been limited in Kenya in the last decade. The government of Kenya has embarked on a highly ambitious reform programme currently being piloted in four Kenyan counties and aiming at national rollout by 2022. This study provides an updated assessment of the performance of the Kenyan health system in terms of financial protection allowing to monitor trends over time. In light of the UHC initiative, the study provides a baseline to assess the impact of the UHC pilot programme and inform scale-up plans. It also investigates household characteristics associated with catastrophic payments. METHODS Using data from the Kenya Household Health Expenditure and Utilization Survey (KHHEUS) 2018, we investigated the incidence and intensity of catastrophic and impoverishing health expenditure. We used a logistic regression analysis to assess households' characteristics associated with the probability of incurring catastrophic health expenditures. RESULTS The results show that the incidence of catastrophic payments is more severe for the poorest households and in the rural areas and mainly due to outpatient services. Results for the impoverishing effect suggest that after accounting for out-of-pocket(OOP) payments, the proportion of poor people increases by 2.2 percentage points in both rural and urban areas. Thus, between 1 and 1.1 million individuals are pushed into poverty due to OOP payments. Among the characteristics associated with the probability of incurring OOP expenditures, socioeconomic conditions, the presence of elderly and of people affected by chronic conditions showed significant results. CONCLUSION Kenya is still lagging behind in terms of protecting its citizens against financial risks associated with ill health and healthcare seeking behaviour. More effort is needed to protect the most vulnerable population groups from the high costs of illness.
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Affiliation(s)
- Paola Salari
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | | | - Stefania Ilinca
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
- European Centre for Social Welfare Policy and Research, Vienna, Austria
| | - Jane Chuma
- The World Bank, Kenya Country Office, Nairobi, Kenya
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Obadha M, Barasa E, Kazungu J, Abiiro GA, Chuma J. Attribute development and level selection for a discrete choice experiment to elicit the preferences of health care providers for capitation payment mechanism in Kenya. Health Econ Rev 2019; 9:30. [PMID: 31667632 PMCID: PMC6822414 DOI: 10.1186/s13561-019-0247-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 10/04/2019] [Indexed: 05/08/2023]
Abstract
BACKGROUND Stated preference elicitation methods such as discrete choice experiments (DCEs) are now widely used in the health domain. However, the "quality" of health-related DCEs has come under criticism due to the lack of rigour in conducting and reporting some aspects of the design process such as attribute and level development. Superficially selecting attributes and levels and vaguely reporting the process might result in misspecification of attributes which may, in turn, bias the study and misinform policy. To address these concerns, we meticulously conducted and report our systematic attribute development and level selection process for a DCE to elicit the preferences of health care providers for the attributes of a capitation payment mechanism in Kenya. METHODOLOGY We used a four-stage process proposed by Helter and Boehler to conduct and report the attribute development and level selection process. The process entailed raw data collection, data reduction, removing inappropriate attributes, and wording of attributes. Raw data was collected through a literature review and a qualitative study. Data was reduced to a long list of attributes which were then screened for appropriateness by a panel of experts. The resulting attributes and levels were worded and pretested in a pilot study. Revisions were made and a final list of attributes and levels decided. RESULTS The literature review unearthed seven attributes of provider payment mechanisms while the qualitative study uncovered 10 capitation attributes. Then, inappropriate attributes were removed using criteria such as salience, correlation, plausibility, and capability of being traded. The resulting five attributes were worded appropriately and pretested in a pilot study with 31 respondents. The pilot study results were used to make revisions. Finally, four attributes were established for the DCE, namely, payment schedule, timeliness of payments, capitation rate per individual per year, and services to be paid by the capitation rate. CONCLUSION By rigorously conducting and reporting the process of attribute development and level selection of our DCE,we improved transparency and helped researchers judge the quality.
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Affiliation(s)
- Melvin Obadha
- Health Economics Research Unit, KEMRI | Wellcome Trust Research Programme, P.O. Box 43640 – 00100, Nairobi, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI | Wellcome Trust Research Programme, P.O. Box 43640 – 00100, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jacob Kazungu
- Health Economics Research Unit, KEMRI | Wellcome Trust Research Programme, P.O. Box 43640 – 00100, Nairobi, Kenya
| | - Gilbert Abotisem Abiiro
- Department of Planning, Faculty of Planning and Land Management, University for Development Studies, Wa, Ghana
| | - Jane Chuma
- Health Economics Research Unit, KEMRI | Wellcome Trust Research Programme, P.O. Box 43640 – 00100, Nairobi, Kenya
- World Bank Group, Kenya Country Office, P.O. Box 30577-00100, Nairobi, Kenya
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Munge K, Mulupi S, Barasa E, Chuma J. A critical analysis of purchasing arrangements in Kenya: the case of micro health insurance. BMC Health Serv Res 2019; 19:45. [PMID: 30658639 PMCID: PMC6339322 DOI: 10.1186/s12913-018-3863-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 12/28/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Strategic purchasing can ensure that financial resources are used in a way that optimally enhances the attainment of health system goals. A number of low- and middle-income countries, including Kenya, have experimented with micro health insurance (MHIs) as a means to purchase health services for the informal sector. This study aimed to examine the purchasing practices of MHIs in Kenya. METHODS The study was guided by an analytical framework that compared purchasing practices of MHIs with the ideal actions for strategic purchasing along three pairs of principal-agent relationships (government-purchaser, purchaser-provider and citizen-purchaser). The study adopted a qualitative descriptive case study design with 2 MHIs as cases. Data were collected through document reviews (regulation, marketing materials, websites) and semi-structured interviews with key informants (n = 27). RESULTS The regulatory framework for MHIs did not adequately support strategic purchasing practice and was exacerbated by poor coordination between health and financial sectors. The MHIs strategically contracted health providers over whom they could exercise bargaining power, sometimes at the expense of quality. There were no clear channels for beneficiaries to provide timely feedback to the purchaser. MHIs premium payments were family-based, low-cost and offered limited benefits. Coverage was based on ability to pay, which may have excluded low-income households from membership. CONCLUSIONS Adequate policy, legal and regulatory frameworks that integrate MHIs into the broader health financing system and support strategic purchasing practices are required. The state departments responsible for finance and health should form coordinating structures that ensure that MHI's role in universal health coverage is owned across all relevant sectors, and that actors, such as regulators, perform in a coordinated manner. The frameworks should also seek to align purchasers' relationships with providers so that clear and consistent signals are received by providers from all purchasing mechanisms present within the health system.
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Affiliation(s)
- Kenneth Munge
- Institution: Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, PO Box 43640 00100, Nairobi, Kenya
| | - Stephen Mulupi
- Institution: Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, PO Box 43640 00100, Nairobi, Kenya
| | - Edwine Barasa
- Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Jane Chuma
- Institution: Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, PO Box 43640 00100, Nairobi, Kenya
- The World Bank, Kenya Country Office, Nairobi, Kenya
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Obadha M, Chuma J, Kazungu J, Barasa E. Health care purchasing in Kenya: Experiences of health care providers with capitation and fee-for-service provider payment mechanisms. Int J Health Plann Manage 2019; 34:e917-e933. [PMID: 30426557 PMCID: PMC6559267 DOI: 10.1002/hpm.2707] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 10/18/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Provider payment mechanisms (PPMs) play a critical role in universal health coverage due to the incentives they create for health care providers to deliver needed services, quality, and efficiency. We set out to explore public, private, and faith-based providers' experiences with capitation and fee-for-service in Kenya and identified attributes of PPMs that providers considered important. METHODS We conducted a qualitative study in two counties in Kenya. Data were collected using semistructured interviews with 29 management team members in six health providers accredited by the National Hospital Insurance Fund (NHIF). RESULTS Capitation and fee-for-service payments from the NHIF and private insurers were reported as good revenue sources as they contributed to providers' overall income. The expected fee-for-service payment amounts from NHIF and private insurers were predictable while capitation funds from NHIF were not because providers did not have information on the number of enrolees in their capitation pool. Moreover, capitation payment rates were perceived as inadequate. Capitation and fee-for-service payments from NHIF and private insurers were disbursed late. Finally, public providers had lost their autonomy to access and utilise capitation and fee-for-service payments from the NHIF. CONCLUSION Through their experiences, health care providers revealed characteristics of PPMs that they considered important.
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Affiliation(s)
- Melvin Obadha
- Health Economics Research UnitKEMRI|Wellcome Trust Research ProgrammeNairobiKenya
| | - Jane Chuma
- Health Economics Research UnitKEMRI|Wellcome Trust Research ProgrammeNairobiKenya
- World Bank GroupKenya Country OfficeNairobiKenya
| | - Jacob Kazungu
- Health Economics Research UnitKEMRI|Wellcome Trust Research ProgrammeNairobiKenya
| | - Edwine Barasa
- Health Economics Research UnitKEMRI|Wellcome Trust Research ProgrammeNairobiKenya
- Nuffield Department of MedicineUniversity of OxfordOxfordUK
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Abstract
This article identifies and describes the reforms undertaken by the National Hospital Insurance Fund (NHIF) and examines their implications for Kenya’s quest to achieve universal health coverage (UHC). We undertook a review of published and grey literature to identify key reforms that had been implemented by the NHIF since 2010. We examined the reforms undertaken by the NHIF using a health financing evaluation framework that considers the feasibility, equity, efficiency, and sustainability of health financing mechanisms. We found the following NHIF reforms: (1) the introduction of the Civil Servants Scheme (CSS), (2) the introduction of a stepwise quality improvement system, (3) the health insurance subsidy for the poor (HISP), (4) revision of monthly contribution rates and expansion of the benefit package, and (5) the upward revision of provider reimbursement rates. Though there are improvements in several areas, these reforms raise equity, efficiency, feasibility, and sustainability concerns. The article concludes that though NHIF reforms in Kenya are well intentioned and there has been improvement in several areas, design attributes could compromise the extent to which they achieve their intended goal of providing universal financing risk protection to the Kenyan population.
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Affiliation(s)
- Edwine Barasa
- a Health Economics Research Unit , KEMRI-Wellcome Trust Research Programme , Nairobi , Kenya.,b Centre for Tropical Medicine, Nuffield Department of Clinical Medicine , University of Oxford , Oxford , UK
| | - Khama Rogo
- c The World Bank Group , Kenya Country Office , Nairobi , Kenya
| | - Njeri Mwaura
- c The World Bank Group , Kenya Country Office , Nairobi , Kenya
| | - Jane Chuma
- c The World Bank Group , Kenya Country Office , Nairobi , Kenya
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14
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Mbau R, Barasa E, Munge K, Mulupi S, Nguhiu PK, Chuma J. A critical analysis of health care purchasing arrangements in Kenya: A case study of the county departments of health. Int J Health Plann Manage 2018; 33:1159-1177. [PMID: 30074642 PMCID: PMC6492197 DOI: 10.1002/hpm.2604] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Purchasing in health care financing refers to the transfer of pooled funds to health care providers for the provision of health care services. There is limited empirical work on purchasing arrangements and what is required for strategic purchasing in low- and middle-income countries. We conducted this study to critically assess the purchasing arrangements of the county departments of health (CDOH) who are the largest purchasers of health care in Kenya. METHODS We used a qualitative case study approach to assess the extent to which the purchasing actions of the CDOH in Kenya were strategic. We purposively sampled 10 counties and collected data using in-depth interviews (n = 81), focus group discussions (n = 4), and documents review. We analyzed data using a framework approach. RESULTS County departments of health did not practice strategic purchasing. The government's (national and county) role as a steward for the purchasing function was characterized by poor accountability and inadequate budgetary allocations for service delivery. The absence of a purchaser-provider split between the CDOH and public health care providers undermined provider selection based on performance and quality. Poor public participation and ineffective complaints and feedback mechanisms limited public accountability and responsiveness to the needs of the people. CONCLUSION Our findings show that while there are frameworks that could promote strategic purchasing of the CDOH, strategic purchasing is impaired by poor implementation of these frameworks and the inherent weaknesses of a public integrated purchasing system that lacks purchaser-provider split.
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Affiliation(s)
- Rahab Mbau
- Health Economics Research UnitKEMRI Wellcome Trust Research ProgrammeNairobiKenya
| | - Edwine Barasa
- Health Economics Research UnitKEMRI Wellcome Trust Research ProgrammeNairobiKenya
- Nuffield Department of MedicineOxford UniversityOxfordUK
| | - Kenneth Munge
- Health Economics Research UnitKEMRI Wellcome Trust Research ProgrammeNairobiKenya
| | - Stephen Mulupi
- Health Economics Research UnitKEMRI Wellcome Trust Research ProgrammeNairobiKenya
| | - Peter K. Nguhiu
- Health Economics Research UnitKEMRI Wellcome Trust Research ProgrammeNairobiKenya
| | - Jane Chuma
- Health Economics Research UnitKEMRI Wellcome Trust Research ProgrammeNairobiKenya
- The World Bank Kenya Country OfficeNairobiKenya
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15
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Kazungu JS, Barasa EW, Obadha M, Chuma J. What characteristics of provider payment mechanisms influence health care providers' behaviour? A literature review. Int J Health Plann Manage 2018; 33:e892-e905. [PMID: 29984422 PMCID: PMC7611391 DOI: 10.1002/hpm.2565] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 06/04/2018] [Accepted: 06/06/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Provider payment mechanisms (PPMs) create incentives or signals that influence the behaviour of health care providers. Understanding the characteristics of PPMs that influence health care providers' behaviour is essential for aligning PPM reforms for improving access, quality, and efficiency of health care services. We reviewed empirical literature that examined the characteristics of PPMs that influence the behaviour of health care providers. METHODS We systematically searched for empirical literature in PubMed, Web of Science, and Google Scholar databases and complemented these with physical searching of the references of selected papers for further relevant studies. A total of 16 studies that met our inclusion and exclusion criteria were identified. We analysed data using thematic review. RESULTS We identified seven major characteristics of PPMs that influence health care providers' behaviour. Of these characteristics, payment rate, the sufficiency of payment rate to cover the cost of services, timeliness of payment, payment schedule, performance requirements, and accountability mechanisms were the most important. CONCLUSIONS Our review found that health care providers' behaviour is influenced by the characteristics of PPMs. Provider payment mechanism reforms that optimally structure these characteristics can elicit required incentives for access, equity, quality, and efficiency in service delivery among health care providers towards achieving universal health coverage.
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Affiliation(s)
- Jacob S. Kazungu
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Edwine W. Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Melvin Obadha
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jane Chuma
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Kenya Country Office, World Bank Group, Nairobi, Kenya
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16
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Tama E, Molyneux S, Waweru E, Tsofa B, Chuma J, Barasa E. Examining the Implementation of the Free Maternity Services Policy in Kenya: A Mixed Methods Process Evaluation. Int J Health Policy Manag 2018; 7:603-613. [PMID: 29996580 PMCID: PMC6037504 DOI: 10.15171/ijhpm.2017.135] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/18/2017] [Indexed: 11/10/2022] Open
Abstract
Background: Kenya introduced a free maternity policy in 2013 to address the cost barrier associated with accessing maternal health services. We carried out a mixed methods process evaluation of the policy to examine the extent to which the policy had been implemented according to design, and positive experiences and challenges encountered during implementation.
Methods: We conducted a mixed methods study in 3 purposely selected counties in Kenya. Data were collected through in-depth interviews (IDIs) with policy-makers at the national level, health managers at the county level, and frontline staff at the health facility level (n=60), focus group discussions (FGDs) with community representatives (n=10), facility records, and document reviews. We analysed the data using a framework approach.
Results: Rapid implementation led to inadequate stakeholder engagement and confusion about the policy. While the policy was meant to cover antenatal visits, deliveries, and post-natal visits, in practice the policy only covered deliveries. While the policy led to a rapid increase in facility deliveries, this was not matched by an increase in health facility capacity and hence compromised quality of care. The policy led to an improvement in the level of revenues for facilities. However, in all three counties, reimbursements were not made on time. The policy did not have a system of verifying health facility reports on utilization of services.
Conclusion: The Kenyan Ministry of Health (MoH) should develop a formal policy on the free maternity services, and provide clear guidelines on its content and implementation arrangements, engage with and effectively communicate the policy to stakeholders, ensure timeliness of payment disbursement to healthcare facilities, and introduce a mechanism for verifying utilization reports prepared by healthcare providers. User fee removal policies such as free maternity programmes should be accompanied by supply side capacity strengthening.
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Affiliation(s)
- Eric Tama
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya.,Institute of Healthcare Management, Strathmore University, Nairobi, Kenya
| | | | - Evelyn Waweru
- KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Jane Chuma
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya.,The World Bank, Kenya Country Office, Nairobi, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Doherty J, Kirigia D, Okoli C, Chuma J, Ezumah N, Ichoku H, Hanson K, McIntyre D. Does expanding fiscal space lead to improved funding of the health sector in developing countries?: lessons from Kenya, Lagos State (Nigeria) and South Africa. Glob Health Action 2018; 11:1461338. [PMID: 29768107 PMCID: PMC5965026 DOI: 10.1080/16549716.2018.1461338] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: The global focus on promoting Universal Health Coverage has drawn attention to the need to increase public domestic funding for health care in low- and middle-income countries. Objectives: This article examines whether increased tax revenue in the three territories of Kenya, Lagos State (Nigeria) and South Africa was accompanied by improved resource allocation to their public health sectors, and explores the reasons underlying the observed trends. Methods: Three case studies were conducted by different research teams using a common mixed methods approach. Quantitative data were extracted from official government financial reports and used to describe trends in general tax revenue, total government expenditure and government spending on the health sector and other sectors in the first decade of this century. Twenty-seven key informant interviews with officials in Ministries of Health and Finance were used to explore the contextual factors, actors and processes accounting for the observed trends. A thematic content analysis allowed this qualitative information to be compared and contrasted between territories. Findings: Increased tax revenue led to absolute increases in public health spending in all three territories, but not necessarily in real per capita terms. However, in each of the territories, the percentage of the government budget allocated to health declined for much of the period under review. Factors contributing to this trend include: inter-sectoral competition in priority setting; the extent of fiscal federalism; the Ministry of Finance’s perception of the health sector’s absorptive capacity; weak investment cases made by the Ministry of Health; and weak parliamentary and civil society involvement. Conclusion: Despite dramatic improvements in tax revenue collection, fiscal space for health in the three territories did not improve. Ministries of Health must strengthen their ability to motivate for larger allocations from government revenue through demonstrating improved performance and the relative benefits of health investments.
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Affiliation(s)
- Jane Doherty
- a Health Economics Unit , University of Cape Town , Cape Town , South Africa.,b School of Public Health , University of the Witwatersrand , Johannesburg , South Africa
| | - Doris Kirigia
- c Kenya Medical Research Institute-Wellcome Trust Research Programme , Nairobi , Kenya
| | - Chijioke Okoli
- d Health Policy Research Group, Department of Pharmacology and Therapeutics , University of Nigeria , Nsukka , Nigeria
| | - Jane Chuma
- c Kenya Medical Research Institute-Wellcome Trust Research Programme , Nairobi , Kenya
| | - N Ezumah
- d Health Policy Research Group, Department of Pharmacology and Therapeutics , University of Nigeria , Nsukka , Nigeria
| | - Hyacinth Ichoku
- e Department of Economics , University of Nigeria , Nsukka , Nigeria
| | - Kara Hanson
- f Department of Global Health and Development , London School of Hygiene and Tropical Medicine , London , UK
| | - Diane McIntyre
- a Health Economics Unit , University of Cape Town , Cape Town , South Africa
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18
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Munge K, Mulupi S, Barasa EW, Chuma J. A Critical Analysis of Purchasing Arrangements in Kenya: The Case of the National Hospital Insurance Fund. Int J Health Policy Manag 2018. [PMID: 29524953 PMCID: PMC5890069 DOI: 10.15171/ijhpm.2017.81] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Purchasing refers to the process by which pooled funds are paid to providers in order to deliver a set of
health care interventions. Very little is known about purchasing arrangements in low- and middle-income countries
(LMICs), and certainly not in Kenya. This study aimed to critically analyse purchasing arrangements in Kenya, using the
National Hospital Insurance Fund (NHIF) as a case study.
Methods: We applied a principal-agent relationship framework, which identifies three pairs of principal-agent
relationships (government-purchaser, purchaser-provider, and citizen-purchaser) and specific actions required within
them to achieve strategic purchasing. A qualitative case study approach was applied. Data were collected through
document reviews (statutes, policy and regulatory documents) and in-depth interviews (n=62) with key informants
including NHIF officials, Ministry of Health (MoH) officials, insurance industry actors, and health service providers.
Documents were summarised using standardised forms. Interviews were recorded, transcribed verbatim, and analysed
using a thematic framework approach.
Results: The regulatory and policy framework for strategic purchasing in Kenya was weak and there was no clear
accountability mechanism between the NHIF and the MoH. Accountability mechanisms within the NHIF have developed
over time, but these emphasized financial performance over other aspects of purchasing. The processes for contracting,
monitoring, and paying providers do not promote equity, quality, and efficiency. This was partly due to geographical
distribution of providers, but also due to limited capacity within the NHIF. There are some mechanisms for assessing
needs, preferences, and values to inform design of the benefit package, and while channels to engage beneficiaries exist,
they do not always function appropriately and awareness of these channels to the beneficiaries is limited.
Conclusion: Addressing the gaps in the NHIF’s purchasing performance requires a number of approaches. Critically,
there is a need for the government through the MoH to embrace its stewardship role in health, while recognizing the
multiplicity of actors given Kenya’s devolved context. Relatively recent decentralisation reforms present an opportunity
that should be grasped to rewrite the contract between the government, the NHIF and Kenyans in the pursuit of universal
health coverage (UHC).
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Affiliation(s)
- Kenneth Munge
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Stephen Mulupi
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Edwine W Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jane Chuma
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya.,Kenya Country Office, The World Bank, Nairobi, Kenya
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19
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Okungu V, Chuma J, Mulupi S, McIntyre D. Extending coverage to informal sector populations in Kenya: design preferences and implications for financing policy. BMC Health Serv Res 2018; 18:13. [PMID: 29316925 PMCID: PMC5761094 DOI: 10.1186/s12913-017-2805-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 12/15/2017] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Vincent Okungu
- Institute of Healthcare Management, Strathmore University, Nairobi, Kenya. .,Pharmaccess Foundation, Nairobi, Kenya.
| | - Jane Chuma
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Stephen Mulupi
- African Population and Health Research Centre, Nairobi, Kenya
| | - Diane McIntyre
- Health Economics Unit, University of Cape Town, Cape Town, South Africa
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20
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Nguhiu PK, Barasa EW, Chuma J. Determining the effective coverage of maternal and child health services in Kenya, using demographic and health survey data sets: tracking progress towards universal health coverage. Trop Med Int Health 2017; 22:442-453. [PMID: 28094465 PMCID: PMC5396138 DOI: 10.1111/tmi.12841] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Effective coverage (EC) is a measure of health systems' performance that combines need, use and quality indicators. This study aimed to assess the extent to which the Kenyan health system provides effective and equitable maternal and child health services, as a means of tracking the country's progress towards universal health coverage. METHODS AND RESULTS The Demographic Health Surveys (2003, 2008-2009 and 2014) and Service Provision Assessment surveys (2004, 2010) were the main sources of data. Indicators of need, use and quality for eight maternal and child health interventions were aggregated across interventions and economic quintiles to compute EC. EC has increased from 26.7% in 2003 to 50.9% in 2014, but remains low for the majority of interventions. There is a reduction in economic inequalities in EC with the highest to lowest wealth quintile ratio decreasing from 2.41 in 2003 to 1.65 in 2014, but maternal health services remain highly inequitable. CONCLUSIONS Effective coverage of key maternal and child health services remains low, indicating that individuals are not receiving the maximum possible health gain from existing health services. There is an urgent need to focus on the quality and reach of maternal and child health services in Kenya to achieve the goals of universal health coverage.
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Affiliation(s)
- Peter K. Nguhiu
- Health Economics Research UnitKEMRI – Wellcome Trust Research ProgrammeNairobiKenya
| | - Edwine W. Barasa
- Health Economics Research UnitKEMRI – Wellcome Trust Research ProgrammeNairobiKenya
- Nuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jane Chuma
- Health Economics Research UnitKEMRI – Wellcome Trust Research ProgrammeNairobiKenya
- The World BankKenya Country Office
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Okungu V, Chuma J, McIntyre D. The cost of free health care for all Kenyans: assessing the financial sustainability of contributory and non-contributory financing mechanisms. Int J Equity Health 2017; 16:39. [PMID: 28241826 PMCID: PMC5327514 DOI: 10.1186/s12939-017-0535-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 02/14/2017] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Vincent Okungu
- Institute of Healthcare Management, Strathmore University, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jane Chuma
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Di McIntyre
- Health Economics Unit, University of Cape Town, Cape Town, South Africa
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22
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Okungu V, Chuma J, McIntyre D. The cost of free health care for all Kenyans: assessing the financial sustainability of contributory and non-contributory financing mechanisms. Int J Equity Health 2017. [PMID: 28241826 DOI: 10.1186/s12939-017-0535-] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
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.
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Affiliation(s)
- Vincent Okungu
- Institute of Healthcare Management, Strathmore University, Nairobi, Kenya.
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
| | - Jane Chuma
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Di McIntyre
- Health Economics Unit, University of Cape Town, Cape Town, South Africa
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Njoroge M, Zurovac D, Ogara EAA, Chuma J, Kirigia D. Assessing the feasibility of eHealth and mHealth: a systematic review and analysis of initiatives implemented in Kenya. BMC Res Notes 2017; 10:90. [PMID: 28183341 PMCID: PMC5301342 DOI: 10.1186/s13104-017-2416-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 02/02/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The growth of Information and Communication Technology in Kenya has facilitated implementation of a large number of eHealth projects in a bid to cost-effectively address health and health system challenges. This systematic review aims to provide a situational analysis of eHealth initiatives being implemented in Kenya, including an assessment of the areas of focus and geographic distribution of the health projects. The search strategy involved peer and non-peer reviewed sources of relevant information relating to projects under implementation in Kenya. The projects were examined based on strategic area of implementation, health purpose and focus, geographic location, evaluation status and thematic area. RESULTS A total of 114 citations comprising 69 eHealth projects fulfilled the inclusion criteria. The eHealth projects included 47 mHealth projects, 9 health information system projects, 8 eLearning projects and 5 telemedicine projects. In terms of projects geographical distribution, 24 were executed in Nairobi whilst 15 were designed to have a national coverage but only 3 were scaled up. In terms of health focus, 19 projects were mainly on primary care, 17 on HIV/AIDS and 11 on maternal and child health (MNCH). Only 8 projects were rigorously evaluated under randomized control trials. CONCLUSION This review discovered that there is a myriad of eHealth projects being implemented in Kenya, mainly in the mHealth strategic area and focusing mostly on primary care and HIV/AIDs. Based on our analysis, most of the projects were rarely evaluated. In addition, few projects are implemented in marginalised areas and least urbanized counties with more health care needs, notwithstanding the fact that adoption of information and communication technology should aim to improve health equity (i.e. improve access to health care particularly in remote parts of the country in order to reduce geographical inequities) and contribute to overall health systems strengthening.
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Affiliation(s)
- Martin Njoroge
- Department of Public Health Research, KEMRI-Wellcome Trust Research Programme, PO BOX 43640-00100, Nairobi, Kenya
| | - Dejan Zurovac
- Department of Public Health Research, KEMRI-Wellcome Trust Research Programme, PO BOX 43640-00100, Nairobi, Kenya
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, CCVTM, Oxford, OX3 7LJ UK
- Center for Global Health and Development, Boston University School of Public Health, 85 East Concord Street, Boston, MA 02118 USA
| | | | - Jane Chuma
- Department of Public Health Research, KEMRI-Wellcome Trust Research Programme, PO BOX 43640-00100, Nairobi, Kenya
| | - Doris Kirigia
- Department of Public Health Research, KEMRI-Wellcome Trust Research Programme, PO BOX 43640-00100, Nairobi, Kenya
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Abuya T, Maina T, Chuma J. Historical account of the national health insurance formulation in Kenya: experiences from the past decade. BMC Health Serv Res 2015; 15:56. [PMID: 25884159 PMCID: PMC4332452 DOI: 10.1186/s12913-015-0692-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 01/09/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Many Low-and-Middle-Income countries are considering reviewing their health financing systems to meet the principles of Universal Health Coverage (UHC). One financing mechanism, which has dominated UHC reforms, is the development of health insurance schemes. We trace the historical development of the National Health Insurance (NHI) policy, illuminate stakeholders' perceptions on the design to inform future development of health financing policies in Kenya. METHODS We conducted a retrospective policy analysis of the development of a NHI policy in Kenya using data from document reviews and seven in depth interviews with key stakeholders involved in the NHI design. Analysis was conducted using a thematic framework. RESULTS The design of a NHI scheme was marked by complex interaction of the actor's understanding of the design, proposed implementation strategies and the covert opposition of the reform due to several reasons. First, actor's perception of the cost of the NHI design and its implication to the economy generated opposition. This was due to inadequate communication strategies to articulate the policy, leading to a vacuum of factual information flow to various players. Secondly, perceived fear of implications of the changes among private sector players threatened support and success gained. Thirdly, underlying mistrust associated with perceived lack of government's commitment towards transparency and good governance affected active engagement of all key players dampening the spirit of collective bargain breeding opposition. Finally, some international actors perceived a clash of their role and that of international programs based on vertical approaches that were inherent in the health system. CONCLUSION The thrust towards UHC using NHI schemes should not only focus on the design of a viable NHI package but should also involve stakeholder engagements, devise ways of improving the health care system, enhance transparency and develop adequate governance structures to institutions mandated to provide leadership in the reform process to overcome covert opposition.
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Affiliation(s)
- Timothy Abuya
- Population Council, P.O Box 17643-00500, Nairobi, Kenya.
| | - Thomas Maina
- Futures Group, Health Policy Project, P.O Box 3170-00100, Nairobi, Kenya.
- Ministry of Health, P.O. Box: 30016-00100, Nairobi, Kenya.
| | - Jane Chuma
- KEMRI-Wellcome Trust Research Programme, P.O Box 230-80108, Kilifi, Kenya.
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
- School of Economics, University of Nairobi, P. O. Box 30197-00100, Nairobi, Kenya.
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Mulupi S, Kirigia D, Chuma J. Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya. BMC Health Serv Res 2013; 13:474. [PMID: 24219335 PMCID: PMC3842821 DOI: 10.1186/1472-6963-13-474] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 10/31/2013] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Health insurance is currently being considered as a mechanism for promoting progress to universal health coverage (UHC) in many African countries. The concept of health insurance is relatively new in Africa, it is hardly well understood and remains unclear how it will function in countries where the majority of the population work outside the formal sector. Kenya has been considering introducing a national health insurance scheme (NHIS) since 2004. Progress has been slow, but commitment to achieve UHC through a NHIS remains. This study contributes to this process by exploring communities' understanding and perceptions of health insurance and their preferred designs features. Communities are the major beneficiaries of UHC reforms. Kenyans should understand the implications of health financing reforms and their preferred design features considered to ensure acceptability and sustainability. METHODS Data presented in this paper are part of a study that explored feasibility of health insurance in Kenya. Data collection methods included a cross-sectional household survey (n = 594 households) and focus group discussions (n = 16). RESULTS About half of the household survey respondents had at least one member in a health insurance scheme. There was high awareness of health insurance schemes but limited knowledge of how health insurance functions as well as understanding of key concepts related to income and risk cross-subsidization. Wide dissatisfaction with the public health system was reported. However, the government was the most preferred and trusted agency for collecting revenue as part of a NHIS. People preferred a comprehensive benefit package that included inpatient and outpatient care with no co-payments. Affordability of premiums, timing of contributions and the extent to which population needs would be met under a contributory scheme were major issues of concern for a NHIS design. Possibilities of funding health care through tax instead of NHIS were raised and preferred by the majority. CONCLUSION This study provides important information on community understanding and perceptions of health insurance. As Kenya continues to prepare for UHC, it is important that communities are educated and engaged to ensure that the NHIS is acceptable to the population it serves.
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Affiliation(s)
- Stephen Mulupi
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya
| | - Doris Kirigia
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya
| | - Jane Chuma
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- School of Economics, University of Nairobi, Nairobi, Kenya
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Abstract
BACKGROUND Many health systems in Africa are funded primarily through out-of-pocket payments. Out-of-pocket payments prevent people from seeking care, can result to catastrophic health spending and lead to impoverishment. This paper estimates the burden of out-of-pocket payments in Kenya; the incidence and intensity of catastrophic health care expenditure and the effect of health spending on national poverty estimates. METHODS Data were drawn from a nationally representative health expenditure and utilization survey (n = 8414) conducted in 2007. The survey provided detailed information on out-of-pocket payments and consumption expenditure. Standard data analytical techniques were applied to estimate the incidence and intensity of catastrophic health expenditure. Various thresholds were applied to demonstrate the sensitivity of catastrophic measures. RESULTS Each year, Kenyan households spend over a tenth of their budget on health care payments. The burden of out-of-pocket payments is highest among the poor. The poorest households spent a third of their resources on health care payments each year compared to only 8% spent by the richest households. About 1.48 million Kenyans are pushed below the national poverty line due to health care payments. CONCLUSIONS Kenyans are becoming poorer due to health care payments. The need to protect individuals from health care related impoverishment calls for urgent reforms in the Kenyan health system. An important policy question remains what health system reforms are needed in Kenya to ensure that financial risk protection for all is achieved.
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Affiliation(s)
- Jane Chuma
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
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van Hoek AJ, Ngama M, Ismail A, Chuma J, Cheburet S, Mutonga D, Kamau T, Nokes DJ. A cost effectiveness and capacity analysis for the introduction of universal rotavirus vaccination in Kenya: comparison between Rotarix and RotaTeq vaccines. PLoS One 2012; 7:e47511. [PMID: 23115650 PMCID: PMC3480384 DOI: 10.1371/journal.pone.0047511] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 09/12/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Diarrhoea is an important cause of death in the developing world, and rotavirus is the single most important cause of diarrhoea associated mortality. Two vaccines (Rotarix and RotaTeq) are available to prevent rotavirus disease. This analysis was undertaken to aid the decision in Kenya as to which vaccine to choose when introducing rotavirus vaccination. METHODS Cost-effectiveness modelling, using national and sentinel surveillance data, and an impact assessment on the cold chain. RESULTS The median estimated incidence of rotavirus disease in Kenya was 3015 outpatient visits, 279 hospitalisations and 65 deaths per 100,000 children under five years of age per year. Cumulated over the first five years of life vaccination was predicted to prevent 34% of the outpatient visits, 31% of the hospitalizations and 42% of the deaths. The estimated prevented costs accumulated over five years totalled US$1,782,761 (direct and indirect costs) with an associated 48,585 DALYs. From a societal perspective Rotarix had a cost-effectiveness ratio of US$142 per DALY (US$5 for the full course of two doses) and RotaTeq US$288 per DALY ($10.5 for the full course of three doses). RotaTeq will have a bigger impact on the cold chain compared to Rotarix. CONCLUSION Vaccination against rotavirus disease is cost-effective for Kenya irrespective of the vaccine. Of the two vaccines Rotarix was the preferred choice due to a better cost-effectiveness ratio, the presence of a vaccine vial monitor, the requirement of fewer doses and less storage space, and proven thermo-stability.
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Affiliation(s)
- Albert Jan van Hoek
- Immunisation, Hepatitis and Blood Safety Department, Health Protection Agency, London, United Kingdom
| | - Mwanajuma Ngama
- Kenya Medical Research Institute, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- * E-mail:
| | - Amina Ismail
- Division of Disease Surveillance and Response, Ministry of Public Health and Sanitation, Nairobi, Kenya
| | - Jane Chuma
- Kenya Medical Research Institute, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Samuel Cheburet
- Health Information System, Ministry of Health, Nairobi, Kenya
| | - David Mutonga
- Division of Disease Surveillance and Response, Ministry of Public Health and Sanitation, Nairobi, Kenya
| | - Tatu Kamau
- Division of Vaccines & Immunization, Ministry of Public Health and Sanitation, Nairobi, Kenya
| | - D. James Nokes
- Kenya Medical Research Institute, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
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Chuma J, Maina T, Ataguba J. Does the distribution of health care benefits in Kenya meet the principles of universal coverage? BMC Public Health 2012; 12:20. [PMID: 22233470 PMCID: PMC3280172 DOI: 10.1186/1471-2458-12-20] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 01/10/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The 58th World Health Assembly called for all health systems to move towards universal coverage where everyone has access to key promotive, preventive, curative and rehabilitative health interventions at an affordable cost. Universal coverage involves ensuring that health care benefits are distributed on the basis of need for care and not on ability to pay. The distribution of health care benefits is therefore an important policy question, which health systems should address. The aim of this study is to assess the distribution of health care benefits in the Kenyan health system, compare changes over two time periods and demonstrate the extent to which the distribution meets the principles of universal coverage. METHODS Two nationally representative cross-sectional households surveys conducted in 2003 and 2007 were the main sources of data. A comprehensive analysis of the entire health system is conducted including the public sector, private-not-for-profit and private-for-profit sectors. Standard benefit incidence analysis techniques were applied and adopted to allow application to private sector services. RESULTS The three sectors recorded similar levels of pro-rich distribution in 2003, but in 2007, the private-not-for-profit sector was pro-poor, public sector benefits showed an equal distribution, while the private-for-profit sector remained pro-rich. Larger pro-rich disparities were recorded for inpatient compared to outpatient benefits at the hospital level, but primary health care services were pro-poor. Benefits were distributed on the basis of ability to pay and not on need for care. CONCLUSIONS The principles of universal coverage require that all should benefit from health care according to need. The Kenyan health sector is clearly inequitable and benefits are not distributed on the basis of need. Deliberate efforts should be directed to restructuring the Kenyan health system to address access barriers and ensure that all Kenyans benefit from health care when they need it.
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Affiliation(s)
- Jane Chuma
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, P.O Box 230, Kilifi, Kenya
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Headington, Oxford, UK
| | | | - John Ataguba
- Health Economics Unit, Department of Public Health and Family Medicine, University of Cape Town, Rondebosch, 7701 Cape Town, South Africa
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Chuma J, Okungu V. Viewing the Kenyan health system through an equity lens: implications for universal coverage. Int J Equity Health 2011; 10:22. [PMID: 21612669 PMCID: PMC3129586 DOI: 10.1186/1475-9276-10-22] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 05/26/2011] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Jane Chuma
- Kenya Medical Research Institute-Wellcome Trust Research Programme, P,O Box 230, Kilifi, Kenya.
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Chuma J, Okungu V, Molyneux C. The economic costs of malaria in four Kenyan districts: do household costs differ by disease endemicity? Malar J 2010; 9:149. [PMID: 20515508 PMCID: PMC2890678 DOI: 10.1186/1475-2875-9-149] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Accepted: 06/02/2010] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Jane Chuma
- Kenya Medical Research Institute-Wellcome Trust Research Programme, P,O Box, 230, Kilifi, Kenya.
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Chuma J, Okungu V, Molyneux C. Barriers to prompt and effective malaria treatment among the poorest population in Kenya. Malar J 2010; 9:144. [PMID: 20507555 PMCID: PMC2892503 DOI: 10.1186/1475-2875-9-144] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 05/27/2010] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Jane Chuma
- Kenya Medical Research Institute-Wellcome Trust Research Programme, P,O Box, 230, Kilifi, Kenya.
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Chuma J, Okungu V, Ntwiga J, Molyneux C. Towards achieving Abuja targets: identifying and addressing barriers to access and use of insecticides treated nets among the poorest populations in Kenya. BMC Public Health 2010; 10:137. [PMID: 20233413 PMCID: PMC2847543 DOI: 10.1186/1471-2458-10-137] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 03/16/2010] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Jane Chuma
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.
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Chuma J, Abuya T, Memusi D, Juma E, Akhwale W, Ntwiga J, Nyandigisi A, Tetteh G, Shretta R, Amin A. Reviewing the literature on access to prompt and effective malaria treatment in Kenya: implications for meeting the Abuja targets. Malar J 2009; 8:243. [PMID: 19863788 PMCID: PMC2773788 DOI: 10.1186/1475-2875-8-243] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 10/28/2009] [Indexed: 11/25/2022] Open
Abstract
Background Effective case management is central to reducing malaria mortality and morbidity worldwide, but only a minority of those affected by malaria, have access to prompt effective treatment. In Kenya, the Division of Malaria Control is committed to ensuring that 80 percent of childhood fevers are treated with effective anti-malarial medicines within 24 hours of fever onset, but this target is largely unmet. This review aimed to document evidence on access to effective malaria treatment in Kenya, identify factors that influence access, and make recommendations on how to improve prompt access to effective malaria treatment. Since treatment-seeking patterns for malaria are similar in many settings in sub-Saharan Africa, the findings presented in this review have important lessons for other malaria endemic countries. Methods Internet searches were conducted in PUBMED (MEDLINE) and HINARI databases using specific search terms and strategies. Grey literature was obtained by soliciting reports from individual researchers working in the treatment-seeking field, from websites of major organizations involved in malaria control and from international reports. Results The review indicated that malaria treatment-seeking occurs mostly in the informal sector; that most fevers are treated, but treatment is often ineffective. Irrational drug use was identified as a problem in most studies, but determinants of this behaviour were not documented. Availability of non-recommended medicines over-the-counter and the presence of substandard anti-malarials in the market are well documented. Demand side determinants of access include perception of illness causes, severity and timing of treatment, perceptions of treatment efficacy, simplicity of regimens and ability to pay. Supply side determinants include distance to health facilities, availability of medicines, prescribing and dispensing practices and quality of medicines. Policy level factors are around the complexity and unclear messages regarding drug policy changes. Conclusion Kenya, like many other African countries, is still far from achieving the Abuja targets. The government, with support from donors, should invest adequately in mechanisms that promote access to effective treatment. Such approaches should focus on factors influencing multiple dimensions of access and will require the cooperation of all stakeholders working in malaria control.
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Affiliation(s)
- Jane Chuma
- Kenya Medical Research Institute/Wellcome Trust Programme P,O, Box 230, Kilifi, Kenya.
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Chuma J, Molyneux C. Estimating inequalities in ownership of insecticide treated nets: does the choice of socio-economic status measure matter? Health Policy Plan 2009. [DOI: 10.1093/heapol/czp021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Chuma J, Musimbi J, Okungu V, Goodman C, Molyneux C. Reducing user fees for primary health care in Kenya: Policy on paper or policy in practice? Int J Equity Health 2009; 8:15. [PMID: 19422726 PMCID: PMC2683851 DOI: 10.1186/1475-9276-8-15] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Accepted: 05/08/2009] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Jane Chuma
- KEMRI/Wellcome Trust Programme, PO Box 230, Kilifi, Kenya
| | - Janet Musimbi
- KEMRI/Wellcome Trust Programme, PO Box 230, Kilifi, Kenya
| | - Vincent Okungu
- KEMRI/Wellcome Trust Programme, PO Box 230, Kilifi, Kenya
| | - Catherine Goodman
- KEMRI/Wellcome Trust Programme, PO Box 230, Kilifi, Kenya
- Health Policy Unit, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK
| | - Catherine Molyneux
- KEMRI/Wellcome Trust Programme, PO Box 230, Kilifi, Kenya
- Centre for Tropical Medicine, University of Oxford, Oxford, UK
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Chuma J, Molyneux C. Estimating inequalities in ownership of insecticide treated nets: does the choice of socio-economic status measure matter? Health Policy Plan 2009; 24:83-93. [PMID: 19218332 DOI: 10.1093/heapol/czn050] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Research on the impact of socio-economic status (SES) on access to health care services and on health status is important for allocating resources and designing pro-poor policies. Socio-economic differences are increasingly assessed using asset indices as proxy measures for SES. For example, several studies use asset indices to estimate inequities in ownership and use of insecticide treated nets as a way of monitoring progress towards meeting the Abuja targets. The validity of different SES measures has only been tested in a limited number of settings, however, and there is little information on how choice of welfare measure influences study findings, conclusions and policy recommendations. In this paper, we demonstrate that household SES classification can depend on the SES measure selected. Using data from a household survey in coastal Kenya (n = 285 rural and 467 urban households), we first classify households into SES quintiles using both expenditure and asset data. Household SES classification is found to differ when separate rural and urban asset indices, or a combined asset index, are used. We then use data on bednet ownership to compare inequalities in ownership within each setting by the SES measure selected. Results show a weak correlation between asset index and monthly expenditure in both settings: wider inequalities in bednet ownership are observed in the rural sample when expenditure is used as the SES measure [Concentration Index (CI) = 0.1024 expenditure quintiles; 0.005 asset quintiles]; the opposite is observed in the urban sample (CI = 0.0518 expenditure quintiles; 0.126 asset quintiles). We conclude that the choice of SES measure does matter. Given the practical advantages of asset approaches, we recommend continued refinement of these approaches. In the meantime, careful selection of SES measure is required for every study, depending on the health policy issue of interest, the research context and, inevitably, pragmatic considerations.
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Affiliation(s)
- Jane Chuma
- Kenya Medical Research Institute, Kilifi, Kenya.
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Molyneux C, Hutchison B, Chuma J, Gilson L. The role of community-based organizations in household ability to pay for health care in Kilifi District, Kenya. Health Policy Plan 2008; 22:381-92. [PMID: 18006525 DOI: 10.1093/heapol/czm031] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is growing concern that health policies and programmes may be contributing to disparities in health and wealth between and within households in low-income settings. However, there is disagreement concerning which combination of health and non-health sector interventions might best protect the poor. Potentially promising interventions include those that build on the social resources that have been found to be particularly critical for the poor in preventing and coping with illness costs. In this paper we present data on the role of one form of social resource--community-based organizations (CBOs)--in household ability to pay for health care on the Kenyan coast. Data were gathered from a rural and an urban setting using individual interviews (n = 24), focus group discussions (n = 18 in each setting) and cross-sectional surveys (n = 294 rural and n = 576 urban households). We describe the complex hierarchy of CBOs operating at the strategic, intermediate and local level in both settings, and comment on the potential of working through these organizations to reach and protect the poor. We highlight the challenges around several interventions that are of particular international interest at present: community-based health insurance schemes; micro-finance initiatives; and the removal of primary care user fees. We argue the importance of identifying and building upon organizations with a strong trust base in efforts to assist households to meet treatment costs, and emphasize the necessity of reducing the costs of services themselves for the poorest households.
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Affiliation(s)
- Catherine Molyneux
- Kenya Medical Research Institute (KEMRI)/Wellcome Trust Collaborative Research Programme, Centre for Geographic Medicine Research, Kilifi, Kenya.
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Chuma J, Gilson L, Molyneux C. Treatment-seeking behaviour, cost burdens and coping strategies among rural and urban households in Coastal Kenya: an equity analysis. Trop Med Int Health 2007; 12:673-86. [PMID: 17445135 DOI: 10.1111/j.1365-3156.2007.01825.x] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ill-health can inflict costs on households directly through spending on treatment and indirectly through impacting on labour productivity. The financial burden can be high and, for poor households, contributes significantly to declining welfare. We investigated socio-economic inequities in self-reported illnesses, treatment-seeking behaviour, cost burdens and coping strategies in a rural and urban setting along the Kenyan coast. We conducted a survey of 294 rural and 576 urban households, 9 FGDs and 9 in-depth interviews in each setting. Key findings were significantly higher levels of reported chronic and acute conditions in the rural setting, differences in treatment-seeking patterns by socio-economic status (SES) and by setting, and regressive cost burdens in both areas. These data suggest the need for greater governmental and non-governmental efforts towards protecting the poor from catastrophic illness cost burdens. Promising health sector options are elimination of user fees, at least in targeted hardship areas, developing more flexible charging systems, and improving quality of care in all facilities. The data also strongly support the need for a multi-sectoral approach to protecting households. Potential interventions beyond the health sector include supporting the social networks that are key to household livelihood strategies and promoting micro-finance schemes that enable small amounts of credit to be accessed with minimal interest rates.
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Affiliation(s)
- Jane Chuma
- Kenya Medical Research Institute, Kilifi, Kenya.
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Hasegawa S, Uenoyaraa R, Takeda F, Chuma J, Suzuki K, Kamiyama F, Yamazaki K, Baba S. A Fully Automatic Method for Analysis of Individual Bile Acids in the Serum Using High-Performance Liquid Chromatography for Clinical Use. ACTA ACUST UNITED AC 2006. [DOI: 10.1080/01483918408068876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Hasegawa S, Uenoyama R, Takeda F, Chuma J, Baba S, Kamiyama F, Iwakawa M, Fushimi M. A highly sensitive determination of individual serum bile acids using high-performance liquid chromatography with immobilized enzyme. J Chromatogr 1983; 278:25-34. [PMID: 6582066 DOI: 10.1016/s0378-4347(00)84752-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
We have developed a highly sensitive method for the simultaneous determination of individual bile acids in serum using high-performance liquid chromatography (HPLC) combined with immobilized 3 alpha-hydroxysteroid dehydrogenase. Both the HPLC column and the immobilized-enzyme column are suitable for use with alkaline solutions necessary in working with this enzyme system. With this method we were able to determine simultaneously fifteen different serum bile acids.
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