A Formative Survey of the Private Health Sector in the Context of the Working Poor.
Insert project name Insert job reference
Prepared for Department for International Development (DFID)
A Formative Survey of the Private Health Sector in the Context of the Working Poor.
Private Sector Innovation Programme for Health (PSP4H)
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Contact Information
Cardno Emerging Markets (UK) Ltd
Oxford House, Oxford Road
Thame
Oxon
UK
OX9 2AH
Telephone: +44 1844 216500
http://www.cardno.com/
Document Information
Prepared for Department for
International Development
(DFID)
Project Name Private Sector Innovation
Programme for Health
(PSP4H)
Date 31st March 2014 (Revised
27th June 2014)
http://www.psp4h.com
Implemented by a Cardno Emerging Markets consortium:
With partners:
Funded by the UK Government:
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List of Acronyms
DFID
FGD
GDP
IDI
KES
KHPG
Department for International Development
Focus Group Discussions
Gross Domestic Product
In-depth Interview
Kenya shilling
Kenya Health Policy Framework
KNSB
KAIS
KDHS
MDG
MOH
M4P
Kenya National Statistics Bureau
Kenya AIDS Indicator Survey
Kenya Demographic and Health Survey
Millennium Development Goals
Ministry of Health
Making Markets work for the Poor
NGOs
NHIF
NHSSP
OOP
PPI
PSP
PSP4H
PPP
Non-government organizations
National Health Insurance Fund
National Health Strategic Plan
Out of pocket
Progress Out of Poverty Index
Private sector providers
Private Sector Innovations Programme for Health
Public private partnership
VfM Value for money
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Recommended Citation
Private Sector Innovation Programme for Health (PSP4H). 2014. A Formative Survey of the Private Health
Sector in Kenya in the Context of the Working Poor. Nairobi: PSP4H
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Foreword
The Private Sector Innovation Programme for Health (PSP4H) is a cutting-edge programme located at the
intersection of private sector development and health care. Funded by DFID and charged with exploring how
a market systems approach might be applied to pro-poor health interventions, PSP4H began in late 2013 by
researching the supply and demand sides of the health care market in Kenya. This research took two forms
– secondary research consolidating the existing body of knowledge, and primary research discovering new
knowledge. The outcome of the primary research has been highly anticipated by the Kenyan health care
community; this report represents PSP4H’s initial publication of knowledge based on new data.
During the period October 2013 through March 2014, PSP4H researchers travelled to 12 Kenyan counties
and conducted focus group discussions with 518 health consumers and service providers to understand the
health-seeking behaviour of the working poor. We held in-depth interviews with 99 key individuals in these 12
counties to explore the supply side of the market as well as the regulatory environment. Finally, we held
open forums with 83 attendees in Nairobi, Mombasa and Kisumu to identify private sector opportunities,
market constraints, and areas where the poor are underserved. The findings of these discussions and
interviews as reported in this document are quite enlightening.
The working poor in Kenya are active market players, consumers with needs to be served in the marketplace
rather than passive beneficiaries. They currently pay out-of-pocket for health care and express a preference
for private providers for reasons of both service and quality. On the other hand, private sector providers
perceive that most poor Kenyans are unwilling and unable to pay for their services. This mismatch of
perceptions and reality underscores a potentially vast (and currently underserved) market for well-targeted
private sector health care initiatives.
PSP4H research highlights new data that should be of great interest to private sector health care investors
as well as public sector policy makers: for example, it answers the question of why the poor prefer the private
sector, and it identifies neglected illnesses for the poor.
As PSP4H proceeds to test business models that better serve Kenya’s poor health consumers, we trust that
our research will help inform the business community about the potential of pro-poor health markets and
stimulate not only more attention to these markets, but also more specific investments that serve the poor.
Ron Ashkin
Team Leader
PSP4H
Nairobi
February 2014
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Preface and Acknowledgement
PSP4H would like to acknowledge the contribution of the following in the realization of this report:
DFID for funding PSP4H; The Centre for Population and Health Research Management, under the
leadership of Rebecca Njue and Timothy Abuya, who contributed to the fieldwork, data analysis and report
writing; The PSP4H team – Ron Ashkin, Chris Masila, Salome Wawire, Dorothy Mbuvi, Barbara O’Hanlon,
Veronica Musembi, Pamela Godia, Ambrose Nyangao, Rachel Gikanga and Joyce Kyalo; and all the
participants in the study, whose insights form the basis of this report.
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Executive Summary
Background
The Private Sector Innovation Programme for Health (PSP4H) is a DFID-funded research programme
implemented by Cardno Emerging Markets and consortium partners. The programme utilizes market
systems approach to strengthen for-profit health sector’s capacity to reach the poor, and ensure that poor
people get better value for the money they spend on health in the private sector. Over the years, the private
for-profit health market has been relatively neglected by government and development partners. There is
little reliable information about the dynamics of the private health care market in many developing country
settings. Additionally, there is little information on how best to intervene in the private health care market to
benefit poor segments of the population. A number of initiatives have been developed through the support of
the United States Agency for International Development (USAID) and International Finance Corporation
(IFC) to support some analysis of the formal for profit sector and initiate policy dialogues primarily involving
private doctors. However there is paucity of approaches and initiatives to support for- profit formal sector that
provides services to the poor. In order to plan affective intervention, PSP4H commissioned an action-
research to synthesize existing information and gather new knowledge about pro poor private sector markets
to improve access for poor people. The overall programme objectives include:
> Assessing and defining who are the poor in Kenya and to better understand their provider preferences,
their health-seeking behaviour, and their willingness and ability to pay for certain health services and
products.
> Exploring under which circumstances the private health sector delivers health services and products to
lower income groups, determining if these services and products are of quality and are affordable, and
concluding if the private health sector services and products actually reach the poor.
> Assessing the Kenyan health market and sub-sectors to identify and pilot appropriate pro-poor
interventions by the private health sector and to conduct action research to establish if the private health
sector can deliver quality, affordable health services that reach the poor.
> Sharing the lessons learned from the different pro-poor health market interventions with Kenyan
stakeholders as well as international practitioners in public health working in developing countries.
To generate evidence for interventions to address inequities in accessing health care in the private sector
and to understand the health seeking behaviour and preferences for the poor, this study was designed to
answer the following questions:
> Who are the working poor in Kenya and what is their profile?
> What are the provider preferences for health care consumers within the PSP4H programme’s target
population?
> What are the health seeking behaviours of health care consumers within the PSP4H programme’s target
population?
Study Methods
The study adopted a cross sectional qualitative survey conducted in 12 selected Counties. A clustered
random sample for the counties was adopted with five large clusters namely: Western and Nyanza province
clusters, North and South Rift regions, North and South Coast regions, Nairobi and Central Kenya regions
and the lower and upper Eastern regions. The criteria for selecting the Counties was based on the under-
five mortality ratios, urban or rural setting, health spending budget for the counties, poverty index, presence
of health financing models targeting the poor, presence of high private sector and the presence of industrial
zones and large farms. On the basis of the above criteria, the following Counties were selected: Kisumu,
Busia, Nyamira, Nakuru, Narok, Garissa, Isiolo, Machakos, Kiambu, Nairobi, Mombasa and Kwale.
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The overall objective of the survey was to explore the definition of who are the poor in Kenya; assess the
working poor health provider preferences, their health-seeking behaviour and their willingness and ability to
pay for certain health services and products; and explore the challenges and opportunities available for
private health providers in the provision of health services and commodities to the poor.
A total of 63 FGDs were conducted with working poor (men and women), health workers in private sectors
and health workers working in retail pharmacy outlets. Sixty five in depth interviews were conducted with
county health managers, facility administrators and owners of private clinics and pharmacies.
In addition, three stakeholder forums were conducted in Nairobi, Mombasa and Kisumu, comprising of
private health care providers, investors, government officials and potential beneficiaries of the PSP4H
programme. The Forums had a total of 100 participants.
Key Findings What we learned about the poor
Who are the poor: There are a number of ways in which poverty is measured. It is multidimensional and
complex in nature and manifests itself in various forms making its definition difficult. Some authors argue that
no single definition can exhaustively capture all aspects of poverty, given its multidimensionality.
In this study we used a qualitative measurement tool to define the working poor (skilled or unskilled causal
and labourers). The tool was developed based on the existing approaches to defining poverty such as the
poverty index, Household Assets Assessment, Monetary/Income and Consumption Expenditure
Assessment, Progress out of Poverty, among others. The criteria used 12 domain areas for scoring on a
scale of 1-3 with the 1 being the poorest and three indicating the wealthy. The scoring indicators covered
housing, house space, rental status, source of water, fuel and cooking security, garbage collection,
sanitation, daily income of household, average number of meals per day, access to health services and type
of work. Those who scored the lowest were recruited in the study.
Health Seeking Behaviour: Health seeking behaviours differed by the illness reported. However, there was
a general pattern for one illness episode: seeking health care sequentially progresses from self-medication,
herbal/traditional care, public health facility to private health facility. In severe cases, the pattern skips the
public facility direct to the private facility. The costs to the poor include payment for services and
commodities at each stage. At the end of the illness episode, they pay more than they would have if they
went straight to a public or private health facility.
The main reason given by the working poor for seeking care in this pattern is lack of money to pay for
services in public and private facilities. Following the health-seeking patterns herein, the reality is that the
monetary cost of one illness episode is more than the cost of the same if care is directly sought at the public
and/or private health facility. Also, there are non-monetary costs such as increase in illness severity, length
of illness episode and economic losses due to extended illness.
Neglected Areas of service to the poor: Most of the working poor who participated in the study mentioned
that the services available to them were generally inaccessible in terms price, quality and physical location.
While there are some focus areas such as HIV/AIDS, malaria, child health and maternal health which are
relatively accessible, there are some areas that are grossly underserved. These are:
> Non-Communicable diseases such as cancer, diabetes and heart disease
> Dentistry
> Gerontological services (age-related illnesses)
> Respiratory infections
> Mental health
The main reason for these areas being underserved was given to be because the fields are highly
specialized and thus lack skilled professionals to provide the service at that level. Also, because of the
specialization in these services, the price tends to be too high for the working poor to afford.
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Ability and Willingness of the Working Poor to pay: The findings in this study show that the working poor
do regularly pay for health services and commodities in the private health sector. The willingness to pay is
contingent upon the perception that private sector services and commodities are of better quality and more
convenient than the public sector. Also, the working poor are willing to pay for services which are
specialized, such as diagnostic and pharmaceutical services, as well as disease-focused services such as
cancer screening and treatment. Also, the consumers indicated that they were willing to pay for services if
they were affordable. However, the health providers held the view that most consumers were unwilling and
unable to pay for private sector services.
What we learned about the private health sector
The focus group discussions with private providers revealed several challenges in delivering services. These
include:
> Enabling Environment. Policies and regulations present several barriers, impacting private providers’
ability to serve the poor. Key among them include: i) lack of policy clarity on private sector’s role and
contribution towards national priorities; ii) regulatory processes are “opaque” and cumbersome; iii)
uncertain MOH support and commitment to the private health sector; weak enforcement of Ministry
regulations and iv) limited incentives to serve the poor.
> Business Climate. Many private providers consider the Kenyan health market attractive for growth and
investment. And the MOH is increasingly receptive to working with the private health sector. Challenges
remain, however, including: i) high cost to set up a health business; ii) high cost of inputs (e.g. drugs,
equipment); iii) poor business and financial management skills. Several private providers also shared
that locating services in poor neighbourhoods brings unique management problems (e.g. security issues,
difficulty to recruit qualified staff, poor infrastructure).
> Market Competition. Private providers stated that competition is a big challenge and comes from multiple
sources: i) competition with informal providers; ii) competition with other private providers; and iii) unfair
competition with other private providers who receive donor subsidies.
> Lack of Information. There are persistent problems of poor communication and information sharing. A
key constraint is the exclusion of the private sector from MOH policy and planning processes. Other gaps
include: i) limited distribution of key government documents and strategies; ii) lack of consistent
communication on updates on regulations; and iii) few clinical training opportunities for the private sector.
Opportunities
With many African countries, such as Kenya, with worsening poverty and health outcomes, it seems ineffective to entirely charge the government with the responsibility of health care for all its citizens. The private sector in health has a role to play in improving health outcome especially among the poor. Table below describes various opportunities and approaches for working with Private Sector Providers PSPs) in the Kenyan market. Matrix of identified strategies to working with PSP for the poor (See next page). The qualitative research reinforces the growing knowledge of the private sector role in delivering services to the poor in Kenya. Although they face many challenges, the private sector is keenly interested in expanding their services to reach more clients – even the poor. Moreover, the research shows that in many cases, the private sector is the provider of choice, yet price makes access to private facilities and providers unattainable. The research revealed several opportunities to expand the private sector role while improving the quality and affordability of their services to benefit the poor. The qualitative study will guide the PSP4H programme as they enter into the design phase to develop partnerships with private providers that will reach the working poor in Kenya.
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Table 7. Matrix of identified strategies to working with PSP for the poor
Intervention objective
Interventions geared towards policy makers
Interventions geared towards providers
Enabling consumers and their representatives
Increase coverage of products and services with a public health benefit which are affordable for the poor
Strategy 1
Lower policy, regulatory and fiscal barriers
Remove barriers to private sector entry to market
Liberalize scopes of practice for key health cadre in private sector
Strategy 2
Recruit and network pharmacies into retail networks
Strategy 3
Recruit PSPs into an accredited network for specific health services with a public health benefit
Strategy 4
Contract with PSPs for packages of essential health care
Strategy 5
Market private sector services among priority target groups
Strategy 6
Introduce demand-side financing to remove economic barriers for priority target groups
Limit harmful practices and improve technical quality of care among PSPs
Strategy 7
Enact and enforce quality standards
Strengthen and enforce provider / facility licensing
Better integrate private sector in quality supervision
Strategy 8
Provide training supports and incentives to PSPs to conform to good practice norms
Strategy 9
Enact consumer protection law and raise awareness of consumer rights
Strategy 10
Increase consumer’s knowledge thru community education campaigns
Make PSP services more affordable
Strategy 11
Publish PSP prices
Encourage price minimums for priority services
Use insurance and contracting to influence prices
Strategy 12
Organize PSPs into group practices, insurance schemes and contracting
Strategy 13
Publish information to users on maximum permitted prices
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Table of Contents
List of Acronyms iii
Recommended Citation iv
Foreword v
Preface and Acknowledgement vi
Executive Summary vii
1 Introduction 13
1.1 Overview of Health Context 13
1.2 Working Poor’s Context on Health 15
1.3 Characteristics of the Private Health Sector 19
2 Methods 22
2.1 Objectives of the Study 22
2.2 Methodology 22
2.2.1 Focus groups and In-depth interviews 23
2.2.2 Description of Study Participants 25
2.2.3 Stakeholder Forums 26
2.3 Challenges in Data Collection 27
3 Findings 28
3.1 Who are the Poor in Kenya? 28
3.2 Working poor’s perspective on healthcare 29
3.2.1 Household decision making dynamics 29
3.2.2 Healthcare seeking patterns 30
3.2.3 Variance in health seeking behaviour 31
3.3 Provider Perspectives 32
3.4 Factors influencing access to health services. 32
3.5 Consumer ability and willingness to pay 33
3.5.1 What are the provider perspectives on consumers’ willingness to pay for health services? 33
3.6 Working poor’s preference for the Private Sector 34
4 Discussion 35
4.1 Overview of Private Health Sector 35
4.2 Private Sector Costs and Prices of Services. 35
4.3 Business Strategies to work with the poor 36
4.4 Private sector clientele 37
4.5 Common Medical Problems 37
4.6 Neglected Health Priorities in the Private Sector 39
4.7 Challenges Confronting Private Sector 39
4.8 The Poverty Penalty 41
5 Policy Recommendations 43
6 References 45
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7 Annex 1: Tools 48
8 Annex 2: Poverty screening tool 56
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1 Introduction
The following is a summary of the literature reviewed to guide the design of the qualitative research and
inform the analysis and recommendations.
1.1 Overview of Health Context
Kenya’s Economic Profile
Kenya is a low income East African country with an increasing population density, although the annual rate
of population growth has fallen since 1979, largely attributed to the expansion of family planning
programmes (KNBS 2010). Improvements in life expectancy after 1970 were reversed in the 1990s largely
due to HIV/AIDS. However, life expectancy has since improved, particularly as AIDS and infant mortality
rates have fallen due to health sector interventions (MOPHS 2009; NCPD 2000) (see table 1).
Table 1. Kenya demographic indicators, 1969-2009
Indicator 1969 1979 1989 1999 2009
Population (millions) 10.9 16.2 23.2 28.7 39.4
Inter-censal growth rate (*) 3.3 3.8 3.4 2.9 2.8
Density (population /km2) 19.0 27.0 37.0 49.0 67.7
% urban 9.9 15.1 18.1 19.4 21.0
Life Expectancy at birth 50 54 60 56.6 58.9 Source: (CBS 1970; 1981; 1989; 1999) (*) period between census is 10 years
In 2007, Kenya had a Gross Domestic Product (GDP) using Purchasing power parity (PPP) of US$57.9
billion or US$1542 per capita (UNDP 2007). The country had a period of increasing economic growth, with
GDP growth rising between 2000 and 2007 as the dividends of changes in government and favourable
global markets improved trade and international funding (Figure 1) (KNBS and ICF Macro 2010). GDP
growth declined dramatically in 2008, however, due to post election violence, increases in food prices, fuel
and fertilizers, and the effect of the global economic crisis (KNBS 2008). Inflation also increased markedly in
this period, only falling again in 2009. Kenya’s economic growth has also been associated with falling
poverty rates from 56% in 1997 to 46% in 2006. Urban poverty recorded the largest decline in that period
from 51.5% to 33.7% (KNBS, 2010).
Figure 1. Gross Domestic Product growth and inflation rates, 2000-2010
Source: (KNBS 2008; 2010; MoH 2007; MOMS 2008; 2010)
By 2007, Kenya had a Human poverty index of 29.5 9 (Figure 2) (UNDP 2007). There is debate about how
widely the benefits of economic growth have been distributed across the population. Kenya’s ‘Vision 2030’,
which sets its national vision, recognizes the need to close disparities between the rich and the poor and to
ensure that all Kenyans benefit from development programmes. While the fall in absolute poverty levels
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suggests that economic growth has benefited poorer groups after 2000, it would be important to assess how
far the commitment in the national vision is being delivered.
Figure 2. Trends in Human Development Index, 1975-2007
0.42
0.44
0.46
0.48
0.5
0.52
0.54
0.56
1975 1980 1985 1990 1995 2000 2004 2005 2007
Hu
man
Develo
pm
en
t In
dex
Year
Source: (UNDP 1980; 1985; 2000; 2004; 2007)
Health Policy Context
The private sector for health in Kenya operates within a policy context shaped by internal and external
influences. A number of key policy documents have shaped the policy landscape including the Kenya Health
Policy Framework (KHPF) of 1994, the National Health Sector Strategic Plan (NHSSP) I: 1999-2004, the
NHSSP II: 2005–2010 amongst others (MoH 2005). The history of health sector reform policies can be
traced back to 1994 with the production of Kenya’s Health Sector Policy Framework Paper (GoK 1994). To
operationalise this document, the ministry of health (MoH) established the Kenya Health Policy Framework
Implementation Action Plan and the Health Sector Secretariat in 1996. In 1999, the MoH produced the
NHSSP I: 1999-2004, which covered a wide range of areas that needed to be strengthened to deliver better
health care to Kenyans. However, these plans were not effectively implemented, prompting the development
of the second five year Strategic Plan II aimed to revitalize the direction of the health sector (NHSSP II) (MoH
2005). The second National Health Sector Strategic Plan (NHSSP II) by the MoH aimed to reverse the
downward trends in health indicators observed during the years of the first strategic plan (NHSSP I, 1999–
2004), while applying the lessons learned and searching for innovative solutions.
More recently, the development of Kenya Health Policy Framework (KHPF) 1994-2010, launching of Vision
2030, enactment of the Constitution 2010, and activities that aims to fast track actions to achieve the
Millennium Development Goals (MDGs) by 2015 are the key milestones shaping the health policy
environment. Currently, the overall focus of health policy in Kenya is guided by Vision 2030, which aims to
‘transform Kenya into a globally competitive and prosperous country with a high quality of life by 2030’
through transformation into an industrialized middle income country (GoK 2011). The health sector policy is
grounded in the principles of the Constitution, specifically the right to health and the adoption of a devolved
system of Governance. Sessional Paper No 6 of 2012 on the Kenya Health Policy (2012-2030) outlines the
policy direction and the long term goals which the Country intends to achieve towards fulfilment of the
Constitution, Vision 2030 and global commitments such as the MDGs.
Health Care Expenditure
According to the 2009/10 National Health Accounts (NHA), the total health expenditure in Kenya was
estimated to be 5.4 percent of GDP at 2010 market prices, translating to per capita health spending of KSh
3,203 (US$42.4). This is a minor increase in per capita health spending from prior levels five years ago at
KSh2,861 (US$ 39) in 2005/06 (MoH 2010). The major sources of financing for the Kenyan health sector
include the government (representing the public sector budget allocation), external donors, individual
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households and other private sector sources. The private sector – by individual out-of-pocket (OOP)
spending 0 is the largest contributor of health funds (36.7 percent), followed by external donors (34.5
percent) and the government (28.8 percent). Of the individual health payments, more than half went to shop-
keepers and for-profit service providers - some of the providers are qualified and licensed but many are not.
1.2 Working Poor’s Context on Health
Challenges in Defining the Poor
The literature on poverty and inequalities indicates that there is a great challenge in characterizing who “the
poor” are. Using a threshold definition (e.g. less than a dollar a day, or using a national poverty line) doesn’t
allow for regional variations and does not adjust for Purchasing Power Parity. A quintile analysis, involving
dividing the population into five equal groups (quintiles) based on an assessment of socioeconomic status
according to a standard of living index, shows that generally, the lower quintiles are more likely to have
poorer access to family planning services (Health Policy Briefs) and general medical care (KNBS and ICF
Macro 2010).
Economic barriers to the poor’s access to healthcare
The Kenya Household Health Expenditure and Utilisation Survey document the health care seeking
behaviour, health care service utilisation, and health expenditures, and can be used to give a snapshot of the
population’s choice patterns in seeking health care. The last survey (MoH & KNBS 2009) demonstrates that
outpatient health utilisation increased from 78% in 2003 to 84% in 2009. The increase in demand for
healthcare is attributable to the overall increase in income. The overall cost per capita of outpatient visits
was KSh 328 and 12% of those utilising outpatient services paid no fee. The wealthiest quintile spends 7
times that of the poorest quintile (Figure 3).
Figure 3. Annual per capita spending for outpatient care
Source: The Kenya Household Health Expenditure and Utilisation Survey 2009
When examining consumer preference, 57% received care at a government facilities, followed by 18% at
private facilities, 15% at a private chemist and at 6% at mission facilities.
Literature shows that payments for health services to contribute to inequitable access to health and
contribute towards household poverty. Studies cite that user fees and other out-of-pockets (OOPs) have
reduced use of health care services, particularly for poorest people, widening disparities in health care
uptake [27-30]. For example, socio-economic and geographic inequities in uptake of services were found to
be wider for inpatient than outpatient care due to the higher and more unaffordable costs of the latter
(Chuma et al. 2007; 2006).
Recognizing user fee’s negative impact on access to health, the Kenyan Ministry of Health policy on user
fees has evolved over time. The Ministry of Health (MOH) introduced user fees in Kenyan in 1989, but
suspended in 1990 due to problems with the hurried implementation; massive declines in utilisation of health
services; lack of quality improvements; and poor revenue collection (Collins et al. 1996; Mwabu 1995; 1995;
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1986). In 1991, user fees were reintroduced in phases starting with tertiary and provincial hospitals, to health
centers and dispensaries. The MOH charged fees for individual services like drugs, injections, and laboratory
services and not consultations. The MOH exempted children under five and for specific services and
conditions such as immunization, management of tuberculosis, and fee waivers for poor people, although
the criteria for these waivers were not clear and may have relied on providers personal judgment.
Exemptions were reported to be cumbersome for both health workers and patients to implement (Collins et
al. 1996).
In July 2004, user fees at primary health care facilities (lowest level of care) were abolished and replaced
with a flat registration fee of Kenya shillings (KES) 10 and 20 for dispensaries and health centers
respectively- commonly known as the 10/20 policy, with the fall noted in the summary table in OOP spending
(MoH 2004). Children aged under five, poor people, specific health conditions like malaria and tuberculosis,
HIV/AIDS and other sexually transmitted infections, maternal health and delivery services were exempted
from paying the registration fees. An initial evaluation of the 10/20 policy reported high adherence to the
policy and an initial increase in utilization of 70%, levelling out to about 30% higher than prior to fee
reduction.
With the reduction of user fees, the revenue collected fell, with drug shortages and ‘overworked’ staff arising
due to the increased utilization. While the policy was popular among patients, it was not supported by health
workers (MoH 2005), and a later evaluation showed that adherence to the 10/20 policy fell, with charges
being raised for registration, injections, drugs, deliveries and laboratory services (Chuma et al. 2009).
To address this in 2005 a pilot project was introduced in Coast province, supported by DANIDA, to
compensate health centres and dispensaries for lost user fees. Under the project health facilities received
money through their bank accounts from the treasury without passing through the MOH (Opwora et al 2010).
While these measures were applied in the public sector, in the private sector out of pocket spending
accounted for 80% of expenditure on health in 2005, with per capita OOP spending of US$ 11.7 in 2003,
higher in urban than in rural areas, and with highest levels in Nairobi (US$ 18.8 in 2003 and the lowest in
Western province (US$ 3.3 in 2003) (Figure 4).
Figure 4. Out-of-pocket Expenditure 2003 and 2007 on Outpatient Visits
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
20.0
Per c
ap
ita e
xp
en
dit
ure i
n U
S$
2003 2007
Sources: (MoH 2004; MoPHS and MOMS 2009)
In 2006, government hospitals were allowed to charge women a delivery fee of US$ 6.5 for normal
deliveries. Mean OOP costs accounted for 17% of households’ monthly income on medical expenses for a
normal delivery, and double this for a complicated delivery. This level of OOP payments did not differ
significantly by socioeconomic status (Perkins et al. 2009). OOP payments impoverish about one million
Kenyan households annually (MOMS and MoPHS 2009), and about 7.7% of low income households incur
catastrophic health expenditure (Carrin et al. 2007). In July 2007, government abolished delivery fees (KSh
300-500) at dispensary and health centre level. While fee charges declined significantly, some fees or
informal charges were still charged to get services, and women had to purchase essential supplies like
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gloves and cotton wool (Perkins et al. 2009). To address the lost revenue from fees and discourage these
additional charges, in December 2007, the Health Sector Services Fund (HSSF) was gazetted as an
extension of the pilot project (discussed previously), which sought to compensate facilities for revenue loss
following user fees reduction through direct transfers from the treasury (MOMS and MoPHS 2009).
OOP spending in the private for profit sector has continued to account for high levels of private expenditure
on health, but has fallen from 2003 levels to US$7.4 per capita in 2007, including in areas of highest
expenditure in Nairobi (US$15.9 in 2007) and Western province (US$3.0 in 2007 (MOMS and MoPHS 2009).
It is not clear what is responsible for this decline, but it suggest that people might have shifted their treatment
seeking patterns towards the public health sector. OOP spending remains an issue in at the hospital level,
and in the private for profit sector, and policy discussions on prepayment mechanisms and social health
insurance discussed later will be important input to providing financial risk protection for all Kenyans from
these charges.
Source: Kenya Demographic and Health Survey 2008-09
It is notable that almost none of the poor reported that they were covered by health insurance, while about
one quarter to one third of those in the richest fifth are covered.
Health seeking behaviour by the poor
Health seeking behaviour plays an instrumental role in determining consumer’s access and acceptability of
health services and products. Proper understanding of health seeking behaviour could reduce delay to
diagnosis, improve treatment compliance and improve health promotion strategies in many different
contexts. A review of the literature on health seeking behaviour show that the several factors determine
consumer behaviours and utilization of a health care system, public or private, formal or non-formal
(MacKian S 2003), the factors that influence the way people utilize health care can be broadly categorized
into five key groups – geographical, social, economic, cultural and organizational.
Thadeus and Maine the “three delays” model helps policymakers and programme managers better
understand how the wide range of factors can directly affect access to healthcare (Thadeus S and Maine D
1994). The three delays model organizes these factors along three action points in the process to seek and
receive healthcare: delay #1 in deciding to seek care, delay #2 in reaching the health facility and delay
#3 in receiving quality care once at the health facility.
Geographical Factors. One of the key factors contributing to greater burden of illness among the poor is
distance to a facility (Kiwanuka SN et al. 2008; Mwaniki PK, Kabiru EW, and Mbugua GG 2002; Buor D
2003; Duff P et al. 2010; Posse M et al. 2008; Kunihira NR et al. 2010; Futures Group Health Policy Initiative
2009). Access is a barrier for Kenyans, particularly those residing in rural areas. Nationally, according to the
2005-06 Kenya Integrated Household Budget Survey approximately eleven percent (11.3%) of Kenyans
travel one kilometre or less to reach a health facility, while about a half (48%) travel five kilometres or more.
Figure 5. Utilization of private providers
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Rural-urban differentials show large disparities in distance to a health facility: only seven point four percent
(7.4%) of rural dwellers travel for one kilometre or less to reach a health facility compared to forty-nine
percent (49%) for the urban residents. In addition, more than a half of rural dwellers travel five or more
kilometres to reach a health facility, while only twelve percent (12%) of urban dwellers travel similar
distances (Central Bureau of Statistics Ministry of Planning and National Development 2005/06).
Socio-cultural Factors. Socio-cultural factors such local beliefs, women’s status and ethnicity have been
associated with delayed treatment. Local beliefs regarding aetiology of diseases strongly influence health-
seeking patterns. For instance, people are likely to consult traditional healers when they believe that an
illness is due to witchcraft. Previous studies on barriers to HIV treatment and care in Kenya found
considerable use of traditional and faith healers (Izugbara CO and Wekesa E 2011; Nagata JM et al. 2011;
Kiragu K et al. 2008). Research has shown that women’s autonomy is an important determinant of utilization
of health services (Chibwana AI et al. 2009). Kenyan men play a paramount role in determining the health
needs of a woman. The unwillingness of husbands to give money to facilitate their spouses to seek care or
lack of cooperation in decision making has been cited as a barrier to women’s access to health care services
(Essendi H, Mills S, and Fotso JC 2010; Tey NP and Lai SL 2013; Shaikh BT and Hatcher J 2005). Ethnicity
has also been found to be an important determinant of uptake of health care services. The Luhya and minor
ethnic groups in the urban slums were more likely than the Kikuyu to have delayed measles vaccination
(Ettarh RR, Mutua MK, and Kyobutungi C 2012). These findings are similar to previous research which
showed that ethnicity was key predictor of parental health seeking for childhood illnesses
(Teerawichitchainan B and Phillips JF 2007)
Socio-demographic Characteristics. Kenyan studies on determinants of utilization of maternal and child
health services have shown that factors such as educational level, age, place of residence, birth parity,
wealth status, exposure to media, knowledge of pregnancy risk factors were associated with use of health
facility delivery (Kenya National Bureau of Statistics (KNBS) and ICF Macro 2010; Mpembeni RNM et al.
2007). The most critical of the socio-demographic factor is a women’s education level, both formal education
and health knowledge. Education is strongly associated with improved maternal and child health outcomes
due to increased awareness of benefits of preventive and curative care. Increased knowledge prompts
health seeking behaviour as well as greater likelihood of adopting healthy practices. Maternal age is another
factor influencing health seeking behaviour. In a KNBS and IFC Macro Study, a mother’s age and the child’s
birth order are associated with a mother’s decision to seek healthcare or deliver at home. Births to older
women and those of higher birth order are more likely to occur with no assistance, compared with births to
younger women and those of lower birth order (Kenya National Bureau of Statistics (KNBS) and ICF Macro
2010).
Economic factors. Countless studies in Kenya and other developing countries highlight the significant
barrier that healthcare costs present to utilization of health services in both private and public sector.
According to the 2007 Kenya Household Health Expenditure Survey (KHHES), over a third of people who did
not seek care (38%) identified lack of money as the reason for not seeking care (KNBS and ICF Macro
2010). This is consistent with evidence from the 2008-09 KDHS which showed that women in Nairobi who
did not deliver in a facility were more likely to cite high cost as a factor than are women in other provinces
(Kenya National Bureau of Statistics (KNBS) and ICF Macro 2010). Data from the national health accounts
show that more than a third of the poor who were ill did not seek care compared to only 15% of the rich (Abt
Associates 2005).
Due to financial constraints, poor people resort to self-medication because they cannot afford to pay for
health care services. The 2005-06 Kenya Integrated Household Budget Survey showed that there is a higher
incidence of self-diagnosis and visiting of kiosks to purchase medicines, especially in rural areas (10%) than
in the urban (4%) areas. The proliferation of pharmacy shops and the common tendency to visit a hospital
only when faced with a serious illness are two reasons cited.
Indirect costs of seeking care creates barriers to utilizations. A study investigating barriers to HIV treatment
and care among children found that indirect costs were a major barrier to paediatric treatment although the
Kenyan government provides free ART. Clients bear additional costs including transport, consultation fees,
and medications to treat opportunistic infections and as a result respondents reported delaying or deferring
care for their children (Kiragu K et al. 2008). Lack of money to pay for transport or hire a vehicle to transport
a pregnant woman to a health facility is a commonly cited barrier to accessing referrals among poor urban
dwellers in Nairobi city (Essendi H, Mills S, and Fotso JC 2010).
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Despite the direct and direct costs, an important percentage of low income households consistently seek
care in private facilities. Significant numbers of Kenyans receive health care in the private facility. Evidence
from the 2005-06 Kenya Integrated Household Budget Survey shows that among the former eight provinces,
forty-seven percent (47%) of the sick in Nairobi visited private health facilities (private hospitals/dispensaries
and clinics). In Coast (26%), Eastern (22%), and North Eastern (26%) provinces the proportion of the
population visiting dispensaries tend to be higher than the national average, while in Nyanza (20.5%) and
Western (22.4%) Provinces, pharmacist/chemist are the most preferred providers. At district level, in
Makueni, Bondo, Trans Nzoia, and Mt Elgon Districts about half of the population sought health care from a
private pharmacists/chemists and kiosks (Central Bureau of Statistics Ministry of Planning and National
Development 2005/06)
Organizational factors. How health services are organized, managed and delivered also influence health
seeking behaviour. Organizations factors include supplies, equipment, staffing, training and qualifications,
and quality of care (MacKian S 2003). Studies conducted among the urban poor in Kenya found that poorly
equipped health facilities in the slums and lack of essential drugs and supplies often discouraged women
from accessing health facility delivery care(Essendi H, Mills S, and Fotso JC 2010; Fotso JC and Mukiira C
2011; Izugbara CO, Kabiru CW, and Zulu EM 2009). Other studies state that many women are reluctant to
seek healthcare because of provider ill-treatment of poor women. When poor women present at facilities,
providers would reportedly abandon them, not listen to them, not ask them important questions. The
providers were also accused of being insensitive to the respondents' cultural beliefs especially during the
birthing process (Macha J et al. 2012; Kiragu K et al. 2008). A study conducted in Kenya, Tanzania and
Ghana shows that poor clients’ choice of a private facility over a public facility appears to be influenced by
the presence of a trained provider at all times (Agha S and Keating J 2009). In Kenya, close to a third (29%)
of providers was found to be absent in a public health facility. At the level of health centres public providers
were three times more likely to be absent than at private non-profit health centres (Martin GH and Pimhidzai
O July 2013). The 2010 KSPA survey found that the prospect of being attended to quickly was cited as
reason for seeking care in private facilities rather than in public facilities, which are associated with longer
lines and waiting times.
1.3 Characteristics of the Private Health Sector
Definition of the private health sector
The Kenyan private health sector is comprised of a diverse range of actors and is one of the largest and
most dynamic in Sub-Sahara Africa. The Ministry of Health now recognizes a pluralistic health system and
defines the private health sector to include “all players outside of the public or governmental sector”. In the
Kenyan context, the private sector includes both informal and formal health providers.
Figure 6 illustrates the wide range of groups and activities
performed by the private health sector in Kenya.
Informal Health Sector
There is scant information on the informal sector in
Kenya, as well as in developing countries more
generally, and much of what is known about Kenyan
informal health providers (IPs) is anecdotal. A recent
Systematic Review of international literature on IPs
identified the most common types of IPs, many of
which are operating in Kenya. The most common IPs in
Kenya include drug sellers; followed by village
doctors/traditional healers; followed by Traditional Birth
Attendants (TBAs), of which there are a significant
number. IPs generally practice poor preventive
medicine, rely on massage and herbal medicines, and
dispense products or services in discrete single dose
units (e.g., drug sellers). TBAs play multiple roles in
pre- and post- natal care that may or may not include
Figure 6. Composition of private sector
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assisting with delivery.
Kenyans living in rural areas are more likely to obtain their health care from one of these types of IPs than
their urban counterparts. The Systematic Review found that IPs are frequently the provider of first choice,
and in some settings the only choice of health care provider, for rural poor households. In fact, depending
upon the country, disease, and measurement method, IPs have been shown to provide as much as 90
percent of the health care used by the rural poor. The three primary reasons that consumers, particularly
poor consumers, use IPs are convenience, affordability, and social and cultural norms. Researchers
estimate that IPs provide between nine and thirty three percent of the health care used by rural poor
Kenyans.
The Systematic Review also showed that quality of care varies widely among IPs and that IPs do not always
adhere to national clinical guidelines. Compared to providers in the formal sector, IPs have very limited
training and frequently lack capacity to provide basic curative services.
Formal Health Sector
Faith-Based Sector. Kenyan Faith-Based Organizations (FBOs) have a long history (over 100 years in
some cases) and long-standing relationships with the MOH. FBOs run almost one-fourth of all health
facilities in Kenya. There are three main faith-based umbrella associations that offer health services to rural
Kenyans, namely, Christian Health Association of Kenya (CHAK), Kenya Episcopal Conference (KEC), and
Supreme Council of Kenya Muslims (SUPKEM).
Non-Government Sector. Kenya has a thriving and active NGO health sector, in large part due to donor
support in response to pressing health priorities like the HIV/AIDS emergency, malaria, tuberculosis (TB) and
family planning (FP). Even though the Kenya Projects Organization (KENPRO) maintains an exhaustive list
of NGOs in Kenya, the exact number of Civil Society Organizations (CSOs) in Kenya working in health-
related activities is not available (HENNET, 2010). The Health NGOs Network Best Practices Technical
Working Group estimated the number to be greater than 6,000.
Commercial Sector. The private health sector is
dynamic and engaged in all aspects of the health
system – pharmaceutical manufacturing and drug
supply; health equipment; health training and
medical education; health financing; hospital
management and care; provision of sophisticated
laboratory and diagnostic services; and, provision of
health services.
The private sector owns, manages and operates
many healthcare facilities in Kenya. This section
provides an overview of health facilities and health
personnel owned, employed and managed by the
private health sector. It also presents MOH data
showing trends in private sector growth, composition and activities since 1999.
Private sector contribution Data compiled by the MOH shows that in 2013, the private sector owned a higher percentage of health facilities than the public sector: fifty-three percent compared to forty-seven percent, respectively (Figure 7). Within the private sector, the commercial sector owns almost three quarters of health facilities (seventy-two percent), followed by FBOs (twenty-two percent) and finally, NGOs (seven percent).
The majority of public facilities are health centres
and dispensaries, while the majority of private,
commercial facilities are clinics and dispensaries.
The public sector has the largest number of
TOTAL FACILITIES 9,448
Quick Facts on the Private Sector
The private sector owns and manages more than half of all the healthcare facilities in Kenya. Within the private sector, the commercial sector owns and operates three quarters of all private facilities. These facilities include primarily health centres and private consultation rooms. The FBO sector operates the majority of private sector hospitals, which are largely located in peri-urban and
rural areas.
Figure 7. Public-private mix of health infrastructure infrastructure
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hospitals (fifty-six percent), followed by the for-profit sector (twenty-five percent) and the not-for-profit sector
(eighteen percent). The private for-profit sector dominates the nursing home segment (mainly small- to
medium-size private hospitals) and health clinics. The public sector and not-for-profit sectors own most of the
health centres and dispensaries.
In 2007/08, the majority of Kenyan health care professionals worked in the private sector, at either a for-profit
or a not-for-profit organization. Almost three quarters of doctors and almost two-thirds of nurses and clinical
officers worked in the private sector in 2007/08. This trend also held true in 2013.
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2 Methods
2.1 Objectives of the Study
As seen in the literature, the private health sector plays a key role in providing health care to all Kenyans,
including the poor populations. The environment in which private health care providers operate is
characterized as unfavourable, owing to policy and regulatory processes that inhibit the provision of optimal
services to the clients, among other factors. Despite these observations, there is little reliable information
about the private sector market. Most studies tend to focus on the health issues rather than the dynamics of
the market itself. There is almost no experience in Kenya, and little globally on effective ways of intervening
in it to benefit poor people.
It is clear that a huge population in Kenya is affected by economic inequalities, which is also reflected in
access to health care. The poor are disadvantaged in this respect, as their access to quality health care is
affected by their limited resources to spend on health care. The poor themselves are not necessarily a
homogenous group and understanding the variability in this broad category may help programmes and
private health providers to focus interventions particular people and needs to maximize access to health
care. In order to understand the health seeking behaviour and preferences for the poor, one needs to
understand the contextual definition of the poor, examine their priorities and concerns about the sector. This
study sought to examine these issues within the context of devolved system of government in Kenya, and
answer the following questions:
The study was guided by the following research questions:
> Who are the working poor in Kenya and what is their profile?
> What are the provider preferences for health care consumers within the PSP4H programme’s target
population?
> What are the health seeking behaviours of health care consumers within the PSP4H programme’s target
population?
> Are the health care consumers within the PSP4H programme’s target population willing to pay for certain
health services and products and to what extent do they have the ability to pay for those products and
services?
2.2 Methodology
The study adopted a cross sectional qualitative survey in the 12 selected counties. A clustered random
sample for the counties was adopted with five large clusters namely: Western and Nyanza province clusters,
North and South Rift regions, North and South Coast Regions, Nairobi and Central Kenya regions and the
lower and upper eastern regions. The criteria for the selecting the counties was based on the under-five
mortality ratios, urban or rural setting, health spending budget per for the counties, poverty index, presence
of health financing models targeting the poor, presence of high private sector and the presence of industrial
zones and large farms. On the basis of the above criteria the following counties were selected: Kisumu,
Busia, Nyamira, Nakuru, Narok, Garissa, Isiolo, Machakos, Kiambu, Nairobi, Mombasa and Kwale counties.
The map below shows the Counties in which the study was done.
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Figure 8. Map of Selected Counties for the Study
2.2.1 Focus groups and In-depth interviews
In each county, five focus group discussion (FGDs) and five in-depth interviews (IDIs) were conducted. The
sampling strategy and assumptions for all the FGD and IDIs are presented in Table 2. In depth interviews
were conducted with county health managers, facility administrators and owners of private clinics and
pharmacies to better understand the supply and demand side of health services to the poor with the counties
and explore the circumstances under which private health sector delivers health services and products to
lower income groups while assessing if these services and products are of good quality and affordable
(Tools in Annex 1). The selection of FGD participants was done through joint community mobilization that
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was conducted by the research assistants and field supervisors with the assistance of the opinion leaders,
community elders and community health workers
Table 2. FGD Sampling Criteria FGD category Selection criteria Underlying assumptions
Women Below 25 years with young children or without Above 25 years with young children
Women influence mainly the health seeking behaviour of the family. The age however of the women influences their health seeking behaviour
Men Working in private/public sector in both formal and informal employments with young families
Make decision on how or when to seek health care
Health workers in private health clinics
Those who provide health services to the poor-large and small facilities
Provide services to the poor. It will help understand the context of the private market
Health workers working in retail pharmacy outlets
Those who provide health services to the poor-large and small facilities
Provide services to the port. It will help understand the context of the private market
The targeted working poor were screened for eligibility using a poverty grading tool (see Annex II). The
FGDs consisted of between eight to twelve participants with discussions lasting one to two hours. Each FGD
was conducted by two trained research assistants—a facilitator and a note-taker. Informed consent was
obtained from all participants before the discussions. The table below summarizes the number of
respondents for this study. A total of 574 respondents both for FGDs and IDI were interviewed (Table 3).
Table 3. Number of participants in the study Methods of data collection Distribution No. of
Respondents
Focused Group discussions With health workers Female Male
62 110
With working poor-men 71
With working poor-women Women over 25 years Below 25 years
166 100
Total FGD participants 509
In-depth interviews Health facility in charges 29
Pharmacy owners 22
County level policy makers 14
Total IDI participants 65
The discussions were tape-recorded in local languages and then transcribed into Word format and translated
to English. There was, however, no back-translation of the transcripts into the local languages. The
transcribed texts were then transferred to NVIVO 10 analysis software and analyzed by three researchers.
Following coding, a full list of themes was available for categorization within a hierarchical framework of main
and sub-themes (Annex III). The development of the thematic framework was based on an initial immersion
of the data from seven sites. These included in depth interviews as well as FGDs with various categories of
actors. The coding framework therefore utilized two main approaches: inductive approaches where two
researchers independently read through the transcripts and developed a set of themes that emanated from
the responses. The emerging themes were then linked with the guide that was used a priori. A tentative
thematic framework was developed for coding. The thematic framework was then systematically applied to
all the transcripts. Patterns and associations of the themes were identified and compared and contrasted
within and between the different groups of respondents. Among clients the focus of the guide was on health
care seeking patterns, decision making dynamics at household level, and cost of services. A total of 68
focused group discussions were held (Table 4).
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Table 4. Type of focus group discussion by site Site Focus Group Discussions
Providers Beneficiaries
women < 25 years women >25 years men > 25 years
Busia 2 2 2 2
Garrisa 2 2 1 1
Isiolo 2 2 2 2
Kiambu 2 2 1 1
Kisumu 2 1 1 1
Kwale 2 1 1 1
Machakos 2 1 1 1
Mombasa 2 1 1 1
Nairobi 2 1 1 1
Nakuru 2 1 1 1
Narok 2 1 1 1
Nyamira 2 1 1 1
Total 24 16 14 14
2.2.2 Description of Study Participants
The Beneficiaries
Male beneficiaries Majority of the Male beneficiaries who participated in the FGDs had completed the O levels up to form 4. Only a few had a gone up to college and 32% had not completed primary education. Most of them were in small business in the jua kali sector, including masonry, farm labour, welding, among other activities. The mean age of the male participant males was 40 years. Female beneficiaries aged below 25yrs In the FGDs with women under 25years, majority of the participants had attained primary level education. A few had completed secondary education. It is also important to note that in Isiolo and Garisa majority had no formal education. Majority in Kwale and Mombasa had only attained primary level education, with only a few proceeding to secondary school. Majority of them were doing small businesses such as selling charcoal, vegetable and fruits, among other activities. The mean age for this group was 22years. Female beneficiaries aged above 25yrs Majority in this group had only attained primary school education level, though there was one who had attained university education and was working as an Mpesa Agent. Close to all the participants in Kwale and Mombasa had only attained primary level education while those in Isiolo and Garisa had not attained any formal education. The mean age for this group was 36 years. Health Care Providers A total of 94 health care providers participated in the study, 48 of the health care providers were female while 51 were male. Majority of the health providers were pharmacist, followed by nurses. The average age for the pharmacists who participated was 26years, nurses was 36yrs, clinical officers 28yrs, lab technicians 29yrs and CHW was 32yrs.
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Table 5. Health Care Providers Interviewed
Gender Number Mean Age Education Occupation
F=18 M=25
43 26.34884 College=28 University=1 Pharmacy
F=25, M=8 33 36.06061
College Nurse
F=2 M=10
12 28.75 Diploma/ certificate -college
C.O
M=2 F=1
3 29
College Lab tech
F=2 M=1
3 32.66667
Certificate - college CHW
Total 94
2.2.3 Stakeholder Forums
In addition to the methods described above, three stakeholder forums were held, one each in Nairobi,
Mombasa and Kisumu. While the forum in Nairobi involved mostly stakeholders from Nairobi County, the
forum in Mombasa and Kisumu included participants from neighbouring Counties - such as Kwale and Kilifi
for Mombasa; and Siaya, Homabay, Kakamega and Vihiga for Kisumu. The government representatives in
Nairobi were from the National office of the MoH while those in Mombasa and Kisumu represented the
County governments.
The purpose of the events was to raise awareness to key stakeholders in the Kenyan health sector – both
public and private– on the PSP4H project, the M4P approach and to interest the private health sector to
participate in the programme. In addition, the forums were used as an opportunity to brainstorm on key
questions regarding the private health sector. The three main questions discussed at the forum were:
1. In what areas of health care are the working poor currently underserved?
2. What for-profit opportunities exist for the private sector to deliver health care to the working poor?
3. What problems and obstacles prevent the for-profit private sector from investing in health care for the
working poor?
The participants represented a wide range of project beneficiaries, organizations and individuals involved
with the Kenyan health sector including government officials from the MoH and finance, county health
representatives, private health sector leaders from umbrella organizations and private provider associations,
private sector investors, consumer organizations and donor agencies. Others included Kenya Health
Federation representatives, Kenya Association of Private Hospital representative, drug manufacturers and
suppliers, medical equipment suppliers, health insurance providers, private health care providers, health
project implementing agencies and health services consumers. The participants were identified through an
initial stakeholder identification process which included direct engagement using the existing networks,
through visits, emails and phone calls.
The forum agenda was divided into three key sessions. The first session covered introductions, including an
opening remark from the hosting county government representative such as the Governor or the director of
health. The second session was a presentation by the PSP4H project, providing background about the
Project and explaining the M4P concept. The third session involved breakout sessions where participants
were divided into three groups to address the above questions. Each group discussed one question from the
three, where they listed answers and later ranked the answers according to level of need and urgency. After
the breakout session, each group presented their views in a plenary session and further discussions were
held with the other members of the other two groups to crystallize the issues. A report for each forum is
appended to this report (Appendix 4).
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2.3 Challenges in Data Collection
Time: Time is an important aspect for the working poor, majority are paid based on hours worked. To
accommodate the tight schedules of the study participants, all interviews were scheduled early in the
morning, at lunch time and late in the evening. Over 80% of the interviews and discussions were conducted
over lunch time and late in the evenings. Due to tight scheduling constraints, organizing a focused group
discussion to constitute more than 8 persons required longer mobilization time.
Availability of County Health Management Teams: The County Health Management Teams (CHMT) were
extremely busy setting up county health systems and thus setting up interviews with them difficult.
Fear of private investigation by sector players: Some of the private sector players were initially afraid that
the survey was investigating their processes, such as availability of licenses. However, proper consenting
and provision of all required information made it easy to set up interviews and FGDs with the private sector
players.
Limitations of the study: The findings of this report may be influenced by the following study limitations
including:
> Given that FGD participants were not randomly selected, their views may not be representative of the
opinions of the general population or of all working poor and health workers. It could be that those who
were approached and agreed to participate in the discussions had strong views about health care in
general and the private sector in particular. However, the fact that some of the qualitative findings—
especially views of the working poor and health workers - on the private sector are consistent with
findings from other studies in the country suggest that the bias is attributable to the nature of the sample
of participants in FGDs may have been minimal.
> FGD sessions may have been dominated by the opinions of a few thereby biasing the findings. However,
apart from being trained to undertake the study, the facilitators were individuals with basic training in
qualitative research and therefore understood the importance of ensuring that the discussions were
balanced.
> Societal attitudes and beliefs may have affected discussion around key areas such as HIV, STIs, and
other services that could have a social stigma. Due to stigma related to these issues, the extent of the
openness with which they were discussed in a FGD may have been compromised.
> Due to financial and time constraints, there was no back-translation of the transcripts to local languages
to determine if some meanings may have been lost in the process of translation to English.
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3 Findings
Sections 3 and 4 offers the findings from the FGDs, IDIs and Open Forum. This section on the poor in
Kenya describes the poor and then delves into: i) how decision are made on health, ii) what influences when
and where the working poor seek healthcare, iii) the poor’s ability and willingness to pay and iv) underserved
health areas the poor need and want.
3.1 Who are the Poor in Kenya?
There are a number of ways in which poverty is measured. It is multidimensional and complex in nature and manifests itself in various forms making its definition difficult (Mariara and GK 2004). Some authors argue that no single definition can exhaustively capture all aspects of poverty. The welfare monitoring survey adopted the material well-being perception of poverty in which the poor are defined as those members of society who are unable to afford minimum basic human needs, comprised of food and non-food items. Although the definition may seem simple, there are several complications in determining the minimum requirements and the amounts of money necessary to meet these requirements (CBS 1997).
The Poverty Reduction Strategy also recognizes that poverty is multi-dimensional. It defines poverty to
include inadequacy of income and deprivation of basic needs and rights, and lack of access to productive
assets as well as to social infrastructure and markets. The PSP4H literature on poverty and health in Kenya
examined several methodologies including:
Household Assets Assessment is one of the approaches used to define the poor and is based on
household ownership of basic amenities such as the source of drinking water, type of sanitation facilities,
materials used for the floor of the house, property ownership and other characteristics that relate to a
household’s socioeconomic status. This approach is commonly used by national sample surveys such as the
Kenya Demographic and Health Survey (KDHS) and Kenya AIDS Indicator Survey (KAIS).
Monetary/Income and Consumption Expenditure Assessment. The proponents argue expenditure is a
better measure of poverty. However, household incomes are not easy to measure because they are not
always a true reflection of actual incomes. Household consumption expenditure is usually a more reliable
indicator. In the context of developing countries, it is often a challenge to accurately measure household
expenditures. The next Kenya health expenditure review is scheduled for release early 2014.
Progress Out of Poverty Index (PPI). The PPI is a poverty measurement comprising ten questions about a
household’s characteristics and asset ownership that are scored to compute the likelihood that the
household is living below the poverty line – or above by only a narrow margin. With the PPI, it is possible to
identify segments of the population that most likely to be poor or vulnerable to poverty. The recent KNBS
study on county income disparity uses PPI.
Using the qualitative approach based on various Participatory Poverty Assessments (PPAs) undertaken
since 1994, the people define, view and experience poverty in different ways. In the third PPA of 2001,
people mainly defined poverty as the inability to meet their basic needs. Poverty was associated with
features such as lack of land, unemployment, inability to feed oneself and one’s family, lack of proper
housing, poor health and inability to educate children and pay medical bills. Though different people and
communities defined poverty differently, poverty was invariably associated with the inability to meet/afford
certain basic needs. Given the multi-faceted nature of poverty, the nature and characteristics of poverty go
beyond income measures alone.
Certain aspects of poverty can be captured by quantitative surveys while others can be established by
qualitative studies. In Kenya the two approaches have been used to generate information on the magnitude,
extent, nature and characteristics of poverty. From both the qualitative and the quantitative poverty
assessments, the poor in Kenya tend to be clustered into certain social categories namely: the landless;
people with disabilities; female headed households; households headed by people without formal education;
Incidence of Poverty
In 2009, 45% of Kenya’s population live below the poverty line
Half of Kenya’s rural population live in poverty
One third of Kenya’s urban residents live below the poverty line
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pastoralists in drought prone certain remote districts; unskilled and semi-skilled casual labourers; AIDS
orphans; street children and beggars; subsistence farmers urban dwellers and unemployed youth.
In this study we used qualitative measurement tool to define the working poor (skilled or unskilled causal and
labourers). The criteria used 12 domain areas for scoring on a scale of 1-3 with the 1 being the poorest and
three indicating the wealthy. The scoring document is presented as an annex. It covered housing, house
space, rental status, source of water, fuel and cooking security, garbage collection, sanitation, daily income
of household, average number of meals per day, access to health services and type of work. Those who
scored the lowest were recruited in the study.
3.2 Working poor’s perspective on healthcare
3.2.1 Household decision making dynamics
The final decision on where, when and how health care is sought is influenced by many factors, one of which is the dynamics experienced at the household level. The research revealed the factors influencing decision making and how they varied by geographic sites. In this study, it emerged that decisions on when and where to seek health care depended greatly on the financial cost of care. For illnesses that were considered severe, and thus financially burdensome, most discussants said the decision was made by the head of the household – who often was the man. The reason for this was that men were the financial providers and custodians in the household, and so decisions that required a significant amount of money was made by them. In a few instances where the woman was the financial provider, they made the decision, such as in female-headed households, households with mothers-in-law, or households where the female member was the main financial provider.
“From what I have seen there are different kind of households there are those that depend on the head of
the house that is the father or the husband.”
FGD, women, Nakuru
Among more traditional communities, health seeking decisions were made by male partners or male
household heads.
“In a household, the man is the head so he makes the final decision of where someone will be taken if sick,
whether to the pastor, hospital or the physician”
FGD-Machakos-Women
In less traditional settings, there are times when decisions are made depending on the urgency of seeking
care. For example, when the child is perceived to be in danger, in most cases the women will take the child
to the hospital and inform the male partner later. In Machakos for example, some respondents felt that,
depending on who is available at the time, anyone will make decision to seek care:
“Anybody close makes decision when one falls ill. I will take the initiative to take someone to hospital if he
falls sick while he is close to me.”
FGD-Machakos-Men
Also, decisions were made on the type of illness and the type of patient. For example, women were expected
to make decisions about care when a child is unwell, just as they are expected to decide on their own health
– especially if it is maternal health. One underlying factor for this is the fact that in the Kenyan system, these
services are available for free and/or subsidized in public and private facilities, and thus do not have financial
implications. The extract below demonstrates these differences.
“From what I have seen there are different kind of households there are those that depend on the head of
the house that is the father or the husband but in some family it’s the individual that”
FGD women –Nakuru
Decision making influenced by:
Financial cost of healthcare
Family structure and cultural perceptions of power at the household level
Perceived severity of the illness
Type of patient
Type of illness
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Figure 9 illustrates two key avenues utilized during decision making process among communities in the
study.
3.2.2 Healthcare seeking patterns
Care seeking patterns appear to be closely linked with the common illnesses cited by study participants. A
general pattern emerged from the consumer interviews. Depending on the illness, a poor consumer first
resorts to self-medication, purchasing some form of medication at a drug shop or kiosk. If the “drug” did not
treat the condition, then the same consumer consults an informal provider because they cannot afford to pay
a private one or the fee at a public facility. Low quality and substandard medication received from the
informal provider often results in the consumer becoming more ill. As the illness progresses, the consumer
now enters into the formal health sector. At this point, the consumer first goes to a public facility. In severe
cases, the consumer will go directly to a private provider. Depending on the illness and cost of treatment, a
poor consumer will bounce between the public and private sectors to get successfully treated.
Figure 10. Client Health Seeking Behaviour
Generally the choice of the source of care at the chemist/pharmacy, private clinic or government facilities
ware mainly determined by;
Access to services: This is most described in the context of distance to the health facility and length of
waiting time for the services. It appears that the short waiting times at the private clinics and pharmacies is
the most important factor that attracts the working poor to seeking services within the private sector. Most of
the respondents explained that their jobs are mostly paid on the basis of hours worked and therefore the
short waiting time at the private clinics and pharmacies favoured them. Further there is a perceived notion
Figure 9. Decision making dynamics for care seeking at household level
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that the private clinics have better quality of care- first it was reported that they often had the supplies and
commodities required, the providers in the private clinics had good communication skills and provided more
friendlier services compared to the public sector.
“We go to the county council hospital because they offer cheap services. On other occasions we go to the
private hospitals because in the government hospitals they only prescribe drugs for us to go and buy from the
chemists, the lines in the public are also quite long so we prefer borrowing money to take our relatives to
private hospitals for treatment-FGD Women Machakos
Quality of care: The quality of care was expressed as real or perceived but both had a significant influence
on the choice of health care by most study participants. These were expressed in terms of availability of
supplies and commodities and friendliness of services offered at the facility. The use of the
chemist/pharmacy was often associated with illnesses not considered serious and often they sought a
prescription from the health workers dispensing the drugs.
Health care cost: The cost of seeking care at the private sector was reported as higher compared to the
public sector. However, the conveniences and quality of care provided at the private health facilities was
seen as the most important facilitating factor to use the private sector.
3.2.3 Variance in health seeking behaviour
While there is a clear pattern to health seeking behaviour reported, there is also notable variation in the way
care is sought. This is defined by the following:
Type of disease: There was indication that people sought care from different providers depending on the
type of disease. For example, most malaria patients opted for “self-diagnosis” and purchase drugs over the
counter. Cancer screening was hardly sought, and in most such cases, health services were sought in
private facilities when the illness had advanced. HIV care seeking behaviour is affected by self-denial and
stigmatization. Few men were reported as seeking immediate HIV care, as a consequence of self-denial or
fear of stigmatization. It was also reported that some of those affected do not utilize ARVs and often prefer to
use herbalists.
“For cancer they don’t go for check-up for early diagnosis, so they just wait until it’s too late.” FGD,
women, Mombasa
The health seeking behaviour for diarrhoea among the working poor appear to be largely buying over the
counter drugs either from a chemist/pharmacy or small retail drugs outlets. This depends on the severity of
illnesses and the location relative to the sources of care.
Type of patient: There was preference to seek care from private health providers or public health facilities
depending on the type of patient. For example, mothers with under-five children often sought at public
facilities due to the fact that health care was free. Other respondents explained that for under-five children
the existence of child that waiting times were much shorter in private clinics and drugs were often available.
Also, women sought maternal health services at public health facilities, given that they are heavily
subsidized.
Severity of the illness: The pattern of health seeking behaviour was altered depending on the real or
perceived severity of illness. For example, for illnesses perceived to be less severe, such as malaria and
diarrhoea, consumers sought care with an herbalists, “self-diagnosis” and over the counter medication, while
for illnesses thought to be severe, such as cancer, consumers were treated at health facilities.
Rural vs. Urban: Generally behaviour between rural and urban poor did not show much variance in terms of
health seeking behaviour. A common pattern revealed is that health seeking among rural poor and urban
poor depends on the type of illness and available health services. As explained by many of the respondents,
for common illnesses such as diarrhoea, cough, fever and other sicknesses like malaria, self-treatment was
taken as a first action while people ‘waited to see’ if the symptoms would go away, preferring to seek
treatment from health facilities if illnesses persisted or worsened. Such conditions do not require complex
laboratory test and are easily treated with ‘over the counter’ medicines which are readily available in shops,
chemists, pharmacy and small drug outlets. Reasons for not seeking treatment from health facilities were
varied. For some, going to hospital for repeated illness was a waste of time, they simply bought the same
drug they were prescribed for the first time they visited the health facility if they perceive the symptoms are
the same.
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I: what do you do when a person falls ill?
R: Buying medicine from the chemist and if persist we go to the city council hospital-FGD-Nairobi
R…we will first go to the chemists for drugs and if the illness persists that’s when we go to hospital. We go
to the chemists to ask for specific drugs that we usually get from the hospitals- FGD, Machakos
Some respondents, both urban and rural prefer using herbal medicines for care and treatment of illnesses.
For urban participants, herbal medicines were mainly sold by vendors, however, some of the rural
respondents cultivated some of the herbs used as medicines in their farms, as explained in the excerpt
below.
I: Are there any traditional drugs that you use when you have a cold? R: There is a drug that the Maasai sell.
I: What is it called?
R: I don’t know, I just buy. They say it treats forty two diseases. When you’re given you just take-FGD
Nairobi
R: There are those who know about traditional herbs so when they get sick they just uproot them and take
them- Mostly people have a belief that traditional medicine works best. And if it doesn’t work you Io to
hospital especially cases of stomach ache, diarrhoea and ring worms FGD-Busia
3.3 Provider Perspectives
The study included a range of facilities from small to large facilities with the number of staff varying with the size of the facility. Smaller facilities have one provider compared to large facilities that have between 2-7 providers. The large pharmacies provide products to retail pharmacies and general shops. Most of the facilities provide basic and comprehensive services. The cadre of staff provides different services ranging from laboratory, pharmacy as well as clinical services. In bigger facilities they have other administrative support staff such as accountants and or clerks. The client load varies from 20-30 per day for the small facilities to up to two hundred clients per day for larger facilities. The flow of clientele also depends on the season such as epidemiological patterns of diseases, festive season or season when finances are available. Smaller facilities see fewer clients as they are still developing a client base.
3.4 Factors influencing access to health services.
Access to services: Access is most commonly referred by the respondents as distance to the health facility
and length of waiting time for the services. It appears that the short waiting times at the private clinics and
pharmacies is the most important factor that attracts the working poor to seeking services with private
providers. Most of the respondents explained that their jobs are mostly paid for hours worked and therefore
appreciate short waiting time at the private clinics and pharmacies.
“We go to the county council hospital because they offer cheap services. On other occasions we go to the
private hospitals because in the government hospitals they only prescribe drugs for us to go and buy from the
chemists, the lines in the public are also quite long so we prefer borrowing money to take our relatives to
private hospitals for treatment”:
FGD Women Machakos
Quality of care: The quality of care was expressed as real or perceived but both had a significant influence
on the choice of health care by most study participants. Informants reported that private sector providers
often had the supplies and commodities required, the providers in the private clinics had good
communication skills and they offered friendlier services compared to the public sector.
Healthcare cost: The cost of seeking care at the private sector was reported as higher compared to the
public sector. However, the conveniences and quality of care provided at the private health facilities was
seen as the most important facilitating factor to use the private sector.
While there is a clear pattern to health seeking behaviour reported, there is also notable variation in the way
care is sought. This is defined by the following:
Key features of private sector providers
Size range from small to large facilities
They operate long hours six-seven days a week
Most of them do not have many branches
They provide services to a variety of clients, including the poor
Most of them rent their premises adding to higher operating costs
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Type of disease: There was indication that people sought care from different providers depending on the
type of disease. For example, most malaria patients opted for “self-diagnosis” and purchase drugs over the
counter. Working poor suffering from diarrhoea appear to be largely buying over the counter drugs either
from a chemist/pharmacy or small retail drugs outlets. Respondents seeking cancer screening, and in most
such cases, health services received care in private facilities when the illness had advanced. HIV care
seeking behaviour is affected by self-denial and stigmatization. As a consequence, few men interviewed
reported seeking immediate HIV care. It was also reported that some of those affected do not utilize ARVs
and often prefer to use herbalists. The use of the chemist/pharmacy was often associated with illnesses not
considered serious and often they sought a prescription from the health workers dispensing the drugs.
“For cancer they don’t go for check-up for early diagnosis, so they just wait until it’s too late.” FGD, women,
Mombasa
Type of patient: The type of patient influenced whether a consumer seeks care from a private health
provider or public health facility. For example, a mother with an under-five child often goes to a public facility
because health care is free. Other respondents explained that for under-five children, the existence of child
clinics made the waiting times much shorter and often the drugs were also available. Also, many women
stated they seek maternal health services at public health facilities given the costs of services are heavily
subsidized.
Severity of the illness: Health seeking behaviour was influenced depending on the real or perceived
severity of illness. For example, for illnesses perceived to be less severe, such as malaria and diarrhoea,
many consumers would see an herbalists, “self-diagnosis” and purchase over the counter medication. While
for illnesses thought to be severe, such as cancer, consumers would seek treatment at a health facility.
3.5 Consumer ability and willingness to pay
The findings from the interviews show that the working poor regularly pay for health services and
commodities in the private sector. The focus group discussions revealed the poor are willing to pay when
they perceive the quality of health services in private sector is better than in the public sector. Also, the
working poor are willing to pay for specialized services, such as diagnostics, specialty care such as
cardiology and cancer treatment, as well as specialized drugs for diabetes and heart disease.
The poor consumers interviewed indicated they prefer private providers and stated they are willing to pay for
more services in the private sector if they were affordable. Interestingly, the private sector providers
interviewed held the view that most consumers were unwilling and unable to pay for their services.
Working poor’s health seeking behaviour has significant financial implications. The research revealed that
the poor have to interact with the health sector more times that their wealthier counterparts, increasing their
out-out-pocket spending with each encounter. Not only do the poor pay out-of-pocket, they incur other non-
monetary costs such as increase in illness severity, length of illness episode and economic losses due to
extended illness. The net effect is a “poverty penalty”.
3.5.1 What are the provider perspectives on consumers’ willingness to pay for health services?
The findings from the interviews show that opinion of health care providers on the consumer ability and
willingness to pay for health services are divided. In-depth interviews with health service providers revealed
that there are those who are sceptical of consumer’s attitudes toward fee-based healthcare services. Asked
about the challenges they face in providing health care, some of the private sector providers interviewed
explained that poor clients were unwilling and unable to pay for their services, as seen in the excerpts below:
Some of the patients are not able to pay because they don’t want to pay, so what we do is prescribe drugs
and then they go. When you look at our clinic, there are so many debts but to minimize it we just give
prescriptions for the patients to go and buy the drugs elsewhere-IDI-Clinic owner-Machakos
I: What about client inability to pay? Do you feel ike it is a challenge?
R: Yes. Some are not able to pay at all. Some get treated and never come back unless they have an
emergency. IDI-Private Hospital-Nairobi
I: How do you treat a poor person and a rich person? Do you treat the same or do you lower the price? Are
there special cases where you can lower the price?
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R: Yes we do consider the pocket because you can’t leave the chemist when you are sick and you don’t have
medication. In pharmacy field we have generic and original…if you aren’t able to buy original and maybe
your situation is not so bad we substitute with generic and it will serve the same purpose-IDI-Pharmacy
owner-Nairobi
3.6 Working poor’s preference for the Private Sector
Several factors explained why the poor are prefer the private
health sector and seek healthcare and services in this sector
despite the economic costs. These factors mirror the literature
review and are primarily driven by the way the private sector
services are organized. How health services are organized,
managed and delivered also influence health seeking behaviour.
The respondents value confidentiality and believe that private
sector providers protect confidentiality more than their public sector counterparts. Many discussed concerns
of confidentiality in terms of laboratory tests and certain illnesses such as HIV.
The second most important factor is the availability of equipment and supplies. The respondents shared that public health facilities lack medicine and often experience stock-outs. The consumers blamed KEMSA for the lack of essential medicines and commodities. Corruption featured prominently in the discussions as well. The interviewees claimed that due to corruption, the MOH providers sell public medicines to private providers; that many public providers steal supplies and use them in their own private practice. And many stated that poor government enforcement of licensing, particularly among informal providers, also creates concerns about quality of drugs.
“So according to me maybe a bit, so with me the
major issue is supplies, they are not adequate. Given a
workload, maybe a given dispensary within the
supplies they get that particular time then maybe the
supplies are over before they get another supply. So it
reaches a time maybe the supply within two to three
months there are no drugs so they intend to throw
these people outside where we get them as private
sectors.”
FGD providers Machakos
Long waiting times in the public facilities was cited as another reason for use of the private sector facilities.
Government facilities were reported to often have long queues. The majority of the working poor reported
being paid on an hourly basis and there waiting time represented loss income.
“Long queues in public hospitals discourage us from going to hospital, so we prefer going to the shops to buy
the drugs.” FGD Men Kisumu
“You are required at your job since are supposed to report at a particular time and your boss does not want to give
you time so you prefer going to the chemist and get quick drugs and go back to work.”
FGD Men Nairobi
Limited or no access to a trained medical staff person is another factor influencing the poor’s use of a private
sector facility. Poor government recruitment is one reason why public sector are understaffed.
“So you find a very good private hospital has seven or ten employees but you will always find over twenty
personnel. Most of them are government employees and they are on contract or locum.”
FGD Health workers Garissa
Finally, private facilities are often open longer hours and on weekends.
“ And another thing to add on top of that one, clients provide their confidence, you see at times like me I get
more calls when am in the house, somebody wants to see me, even if I try my best to connect that particular
patient to the staff in the public sector he cannot willingly go there. He just waits for me until I come and
provide that drug for that patient. So that confidence actually is a contributory factor to people flowing into
private sector and avoiding going to public. FGD providers Mombasa.
Neglected illnesses for the poor
Non-communicable disease (cancer, diabetes, heart disease)
Dentistry
Gerontology
Respiratory infections
Metal health
Reasons why poor prefer the private sector Perceived quality of services
Confidentiality
Convenience (longer working hours)
Easy access to the facility
Positive provider attitude and behaviours
Availability of specialised services
Shorter waiting times
Availability of staff, particularly doctors
Availability of equipment and supplies
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4 Discussion
This is the second section of key findings and is focused on the private health sector and their role in
delivering health services and products to the working poor. Section 4 focuses on private sector prices and
their strategies to help the working poor pay, a description of the range of clientele served by the private
sector, the most common illnesses that the private sector finds among the working poor, and concludes with
the principle challenges they confront.
4.1 Overview of Private Health Sector
The study interviewed a range of private providers who
managed and operated facilities ranging from small to large
facilities located in both urban and rural areas. The smaller
facility typically had one provider – the owner/physician.
These facilities aim to deliver basic yet comprehensive
services including laboratory, pharmacy as well as clinical
services. The client load varies from 20-30 per day for the
small facilities. Smaller facilities see fewer clients as they are
still developing a client base.
On the other hand, the larger facility employed two to seven providers in addition to administrative staff such
as accountants and/or clerks.
The larger facilities would serve upwards of two hundred patients daily. Larger pharmacies would also
provide products to smaller retail pharmacies and general shops in their catchment areas.
The flow of clientele also depends on the season such as epidemiological patterns of diseases, festive
season or season when finances are available.
4.2 Private Sector Costs and Prices of Services.
Prices charged in the private sector Prices charged in the private vary depending on the size, type of facility and location. Some providers have a price list accessible to clients but it is often subject to change. In some cases, providers purposely do not display their price list as a strategic move to charge different prices depending on the perceived ability of the client to pay. Although the private sector prices are higher than the fees and other incidental costs consumers need to pay in the public sector, the private providers interviewed generally thought their prices are too expensive because their clients often came back for more services. The average prices provided for different services are presented in Table 5 below. Table 2. Private sector prices of services Costs of services Type of services
Free – KES 330 HIV testing
Free Treatment of TB
KES 150-300 Family panning
KES 8000 Maternity services
KES 100 Malaria lab test
KES 100-200 Typhoid
KES 200 Blood sugar tests
KES 200 Urinalysis
KES 100 Stool
Cost drivers for private practices
Private provider reported that operating costs are the main drivers. These include labour, rent, utilities such
as water and power, drugs and other supplies, and finally license fees. Most of the providers reported that for
effective service delivery, the private sector providers may need working capital to increase their ability to
deliver quality services.
Key features of private providers interviewed
Size ranges from small- to large
Operate longer hours than the public sector – six days weekly
Most providers own and manage only one facility
Most private providers interviewed serve the poor
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“Electricity sometimes goes up; you know here electricity must be used for 24 hours. You find electricity bill is
very high”
FGD chemist workers Nairobi
“We pay 30,000 per month and license for the whole year is 25,000.”
IDI Health facility owner Machakos
“The major cost of a product that consumes most of our budget is medicine including the laboratory reagents
which are also consuming quite a lot. Of course I’m talking about recurrent expenditures because I’m
assuming the machines are already in place. So it is just drugs, salaries. I think those will be the major costs.”
IDI Health facility owner Busia
Setting prices Private providers understand the relationship between costs and price. The private providers also shared the various factors influencing how they set their prices (See Text box). The factors are presented in order of importance. Key among them is competition with other private providers in their community. Another is clientele; many demonstrated flexibility in pricing due to poverty and economic hardship. Private providers help their poor clients by either reducing the price or by offering flexible payment modes like payment in instalments.
“The price is determined by your cost. Until you receive goods from the supplier and check the invoice that is
when you can tell your price.”
FGD providers, Busia
“…And it’s known in pharmacy. You multiply by 1.33. if you want to know the cost of selling an item, you
multiply the price you purchased the products with 1.33 to retail price.”
FGD providers Nyamira
Private provider accept payment through a variety of mechanisms which is linked to the size of the private
facility. Clearly smaller providers rely on cash payment and at times, in-kind payments. While the larger
facilities could accommodate checks, Mpesa and insurance – both public and private mostly in urban areas.
The mechanism preferred and used for payments was reflective of the scale of the health facility and the
type of clientele they serve. For example the larger facilities served patients with health insurance and
checks, and were mostly located in urban areas. The smaller facilities accepted cash (OOP) and Mpesa
payments, and were located in rural and peri-urban areas.
4.3 Business Strategies to work with the poor
Marketing strategies
Few private providers use market to reach new clients and thereby expand services. There are several
reasons why:
> The medical community, particularly doctors, believe that it is not appropriate and not needed
> The cost of advertising is prohibitive for small business.
> Limited knowledge and experience by private health sector to market their products and services.
“We belong to the xxx whereby we were not allowed even to advertise you just write xxx Medical Clinic then
you offer the services which is required then that one will advertise for itself.”
IDI Health facility owner Machakos
Bigger facilities do have experience in marketing and utilized mainstream media to advertise themselves.
Marketing activities include use of flyers, bill boards, radio and television spots and more recently social
networks. Smaller facilities tend to rely on “word of mouth” based on delivering good quality service and
client service.
Factors influencing provider prices Operating costs, particularly staff
and drugs
Competition with other providers
Type of clients
Location of services
Cost of license (provider and facility)
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Financing strategies
Access to capital appears to be a major challenge for private sector providers, which affects expansion and
quality of service provision. Most private providers noted that the start-up capital is largely based on
investor/provider savings or through loans. Occasionally, there is donor support linked to faith-based
facilities. Continuous capital support often comes from credit facilities, especially with regards to supplies.
The credit system operates under different arrangements as agreed upon by the service provider and the
finance provider.
“When you want credit somehow we are given credit when you are a regular customer there you see then
you leave your details also there when you are given credit then you are given 6days or 30 days to settle.”
IDI Health facility owner Isiolo
4.4 Private sector clientele
Client profile
The study also explored the characteristics of clients who frequent the private sector. Findings show that the
private sector serves both the poor and the rich alike. The private sector providers interviewed estimated that
their poor clientele earn about 3000 Kenya shilling per month. The clients are geographically spread out
depending on the locations of the facilities.
Moreover, the findings revealed that the private sector targets all persons along the socioeconomic
spectrum. This strategy permits private providers to boost client volume which helps drive their unit costs
down; to better manage cash flow and to cross subsidize their poor clientele who cannot afford to either pay
full price or have to pay on instalments.
Ability/willingness to pay for private services
In general, the private providers interviewed shared that their clientele were willing to pay for services
because most of the services they offered were not available in the public sector. These providers noted,
however, that their clientele’s ability to pay for the services was somewhat diminished by the ‘high’ prices set.
Some of the private providers have made attempts to estimate the cost clients were willing to pay for various
services. For maternity services majority of the female respondents reported a price of KES 2500, while for
common illness such as flu, they reported paying approximately KES 200-500. The excerpts below
demonstrate consumer’s perceptions on affordability and willingness to pay.
“We should be allowed to use the NHIF cards even if we are not being admitted to the hospital. For illnesses
like common cold we should be charged about 200 Shillings, at most 500 Shillings, this is because those
people are there for business and they have to pay rent and the staff.”
FGD women, Kwale
“They should even consider reducing the fees they charge to their clients. Maternity fees worth 8000 Shillings
is so expensive, if it was 2500 Shillings it would be fair.”
FGD women, Nakuru
Private provider flexible terms of payment
The private sector has developed two main ways to accommodate the poor. First, the poor pay as much as
the rich for drugs and other health commodities but are allowed to pay for half doses of medicines or pay in
instalments. This coping system may enhance drugs resistance through irrational drugs use. It also depicts
a repeated cycle of potentially inadequate treatments that may spur repeated visits, making access to care
expensive. The second approach is to allow alternative modes of payment that attract a value that may be
monetary or otherwise.
4.5 Common Medical Problems
The common illnesses that private providers see among the working poor included HIV/AIDS, malnutrition,
diabetes, pneumonia, malaria, cancer, diarrhoea, typhoid and anaemia. In addition to the illnesses identified
by the working poor, health workers mentioned urinary tract infections, respiratory infections, pelvic
infections, intestinal worms. Specifically for Isiolo County the health workers identified brucellosis as a
common illness whereas in Mombasa and Kwale counties conjunctivitis was often mentioned. The main
types of cancers identified were breast, cervical and kaposis sarcoma.
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“Ok, generally, HIV aids very common, Aids leading to other diseases like tuberculosis, yeah.” FGD Health
workers Kwale
When asked to prioritize, health workers in this study identified HIV, cancer, diarrhoea, malaria and
pneumonia. However, many health workers felt that there were additional priority illnesses specific to
children – upper respiratory illnesses and malnutrition.
“Even malnutrition they don’t seek treatment. When the child is
about to die is the time they go to the hospital. They lack
knowledge and understanding of seriousness of malnutrition
and at times they are ashamed.”
FGD Health workers
“Like today out of the 20 cases that we had 4 of them were
diarrhea cases so in other facilities they may change because it
depends on the month and the season in other seasons the
frequency increases like last December the frequency was high
so you find even the most admission cases in children are
diarrhea like during the rainy season the cases are high”
FGD providers Nakuru
Four key differences emerge in the type of illnesses that are commonly experienced across private sector
sites.
Differences between the diseases cited by women and men. For example, women and men also cited
different illnesses such as problems during the menstrual cycle, stomach aches and ulcers. There were no
major differences between women under 25 years and those above 25 in terms of illnesses that were
commonly experienced. However men over 25 years in Machakos pointed falls from construction sites as an
additional problem.
“Injuries that people get while fighting or at work for example falling during construction” FGD Women
Machakos
Differences in common illnesses based on seasonality and geography. Geographic variations linked to
either rainy or sunny periods of the year were noted. Geographical location, with arid and semi-arid region
citing diseases such as malaria, typhoid, diabetes, blood pressure, HIV/AIDS, diarrhoea, sleeping sickness.
It is also clear that the location of certain features such as presence of army barracks and tourist sites was
perceived to propagate certain illness for example in Isiolo women noted.
“Episodes of malaria is not seasonal it is all the time. Pneumonia occurs during the cold season, That is...in
term of seasons that is during the colds season that is from March to May.”
FGD Women Busia
“Are many people affected with TB? Yes, we have Muslims and because of their customs of eating the
prevalence is high. The rate of HIV/AIDS is high because of a lot of army barracks here in Isiolo County and
the women and girls go to town to be with them. Pneumonia affects the motorbike drivers on the road
because of the cold.”
FGD Women Isiolo
In Busia the top diseases were malaria and ring worms. In Isiolo, they ranked malaria and HIV/AIDS as the
most common illnesses, especially as experienced by women. In Kiambu pharmacists based the common
illnesses on what drugs sell most.
“Malaria it occurs during the rainy seasons, HIV/AIDS the 2nd because they are many drunkards who sleep
around under the influence, typhoid because our water is really dirty and not of standard, TB because these
area is a dry land and pneumonia”
FGD health workers Isiolo
“Flu, common cold, chest conditions like bronchiolitis, abdominal discomforts like diarrhea, typhoid fever,
brucellosis and dysentery” FGD health workers Kiambu
“I think is malaria, diarrhea and vomiting, ring worms and I think we had forgotten epilepsy and lastly HIV
and AIDS in that order.”
Private Providers top five diseases among working poor
HIV/AIDS
Cancer
Diarrhea
Malaria
Pneumonia Among poor children
Upper respiratory illness
Malnutrition
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FGD-Health workers Busia
In other sites such Narok and Busia dental problems were cited as a common problem.
“There are quite a number of problems, for me am in dental department so the main problems there is the
dental carries and other dental diseases I think those are the major diseases that we deal with in dental
department”
FGD-Providers Narok
“Tooth decay is also a problem you find someone has all the teeth rotten it is called dental tooth decay if you
go to hospital when they pull the tooth out the healthy one also start decaying and if you take it to the
Nambale Centre the doctors there are not qualified they just pull the tooth out just for the sake and you get
infections which sometimes lead even to death”
FGD women-Busia
Difference in illnesses based on demographics. In Busia, women cited variations with the age groups with younger children experiencing certain condition.
“Skin rushes on children are also so rampant children below five months you get that they have rushes all over if you
take them to hospital they give you amoxilin and it doesn’t work and colds also when you walk you find that
everybody has a cold just that.”
FGD women Busia
4.6 Neglected Health Priorities in the Private Sector
Most of the working poor who participated in the study mentioned
that the services available to them were generally inaccessible in
terms of price, quality and physical location. While there are health
priorities such as HIV/AIDS, malaria, child health and maternal health
which are relatively accessible, there are others areas that are
grossly underserved.
The main reasons cited why the working poor do not receive these
services were health workers in medical facilities in their
communities lack training and skills in specialties, and the price for these services tend to be too high for the
working poor to afford.
4.7 Challenges Confronting Private Sector
The private providers interviewed experience many
challenges similar to private providers in other developing
countries. The challenges found through FGD and IDIs are
organized by enabling environment, business climate,
competition and asymmetry of information.
Enabling Environment. Stakeholder interviews with
private providers highlighted many of the legal and
regulatory barriers they confront, particularly in serving the
poor. They include:
Private sector role and contribution towards national priorities unclear: To date, there is still no MOH policy
and strategy on how to engage and work with the private sector. There is no consensus or clarity on what
role each sector should play, and under which conditions each sector should pay its role. The private sector
is often unaware of national health priorities and therefore unable to align its activities to address these
priorities.
Regulatory processes “opaque” and cumbersome: Institutional arrangements and transparent procedures to
partner with the private sector do not exist. And private providers have to negotiate a myriad of MOH
departments to secure the necessary approvals and licenses to operate as a private and health business.
Uncertain MOH support and commitment to the private health sector: The health sector is currently
experiencing a lot of change and turmoil. There is a new MOH administration in place and to date, they have
had limited dialogue with the private health sector.
Neglected illnesses for the poor
Non-communicable disease (cancer, diabetes, heart disease)
Dentistry Gerontology Respiratory infections Metal health
“The main challenge is one because of the old mistrust, again if you find some private practitioners will not meet the standards of the equipment’s. Once the guy puts up a hospital he might not employ the qualified people and he might not have the right equipment’s. So you go there and tell them that you cannot start until you meet the basic requirements”.
IDI, private clinic owner, Busia
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> Weak enforcement of government rules: The private
sector largely continues to operate with minimal
oversight. Quality in the private health sector, still a
major concern, can be significantly improved through a
combination of better enforcement and incentives. The
MOH has many of the instruments in place but has
underinvested in capacity to enforce standards and
norms.
> Limited incentives to serve the poor: The MOH does not have in place a strategy and/or policy guiding
the public and private sectors to focus its efforts to reaching underserved population groups like the poor.
And the government does not routinely use incentives - such as tax relief, certificate of needs, and
subsides - encouraging the private sector to invest in health services reaching the poor.
Business Climate. Many private providers consider the Kenyan health market attractive for growth and investment and the government has become more receptive to working more directly with the private health sector. Challenges remain, however, including: > High Cost to set up a health business: Most private
providers consider existing regulations to be reasonable
and welcome the opportunity to be fully licensed as a
competitive advantage with consumers. However,
managing multiple licenses and inspections from different regulatory agencies is confusing, costly and
time consuming, resulting in higher cost to entry.
> High cost of inputs: Staff and drugs are the two main cost drivers in a health business. Others cited the
equipment as well as the high cost of property in urban areas.
> Access to finance: In general, larger hospitals and pharmaceutical manufacturers have access to formal
credit. However, smaller facilities and solo practitioners – the private provider group most likely to serve
the poor – cite access to finance as a major constraint. Lack of access limits private provider capacity to
expand services and invest in quality improvements.
> Poor business and financial management skills: Many small private practices do not have some of the
basic tools and skills to analyse costs or profits. Moreover, several provider recognize they struggle to
identify potential target market and lack skills to market to prospective consumers.
> Locating services in poor neighbourhoods brings unique management problems: Government investment
in infrastructure are concentrated in urban neighbourhoods – not poor communities – driving the start-up
cost for basic inputs like water and electricity. Crime and political insecurity is higher in peri-urban areas,
making it difficult to attract skilled workers, there are fewer trained personnel in/or near these
communities, and specialists are unwilling to commit to working in these communities.
Market Competition. Private providers state that competition is a big challenge and comes from multiple sources. > Competition with informal providers. Private providers
consistently reported that unlicensed facilities and/or
illegal workers in the informal sector represent one of
the most difficult areas of competition. Such facilities
are reported to have lower prices compared to those who are fully licensed and employ qualified
personnel
> Other private providers. The private for-profit health sector is dominated by small private practice – solo
practitioners. Because of competition with other small practices, many private providers feel compelled to
invest in medical equipment to attract consumers. There is little incentive and limited experience in
forming “group” practices to minimize risk.
“Because they discriminate against people from
the private sector and then the rampant levels of
corruption, for instance the drug inspectors they
are government personnel but they are coming to
harass us in our facilities, they are just after
money.”
FGD, Health workers, Machakos
“There a district hospital around. There prices are
very low compared to ours, you know the prices
are subsidized by the government but with us we
get them directly from the suppliers.”
IDI, pharmacy owner, Nyamira
“The high cost of equipment’s and lack of skills of
the health providers are our challenges, we also
have the inability of clients to pay and lack of
awareness that this clinic exist and that is why we
do sensitization of the community often.”
IDI, Clinic owner, Isiolo
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> Competition with the public sector. Many of the private providers claim “stiff competition” from MOH
services. Often middle income clients switch providers to receive certain services, such as deliveries, for
“free” or at a “subsidized” rates in government facilities. It is difficult to compete with MOH who receive
access to favorable prices for key inputs such as infrastructure, drugs and equipment.
> Crowding out by donor subsidies. There are two forms of donor subsidies creating unfair competition:
first, free products “dumped” in the market place such as free FP methods, childhood vaccines and
malaria bednets and second, subsidized inputs to private providers participating in donor programmes.
Private providers they cannot compete with free products or reduced prices artificially created through
donor subsidies.
Asymmetry of Information. There are persistent problems of poor communication and information sharing.
On the public sector side, the MOH struggles to motivate the private health sector to regularly report its
activities to the MOH health management information system. On the private sector side, one key constraint
is exclusion from MOH policy and planning processes and limited communication between sectors.
Information gaps include:
> National health of priorities: Private sector lacks information due to infrequent participation in policy
formulation and planning processes, limited distribution of key government documents and strategies and
no interaction between the sectors.
> Regulations and standards: The MOH often does not include private sector organizations in its efforts to
update and modernize regulations and standards, does not consistently communicate important changes
in and/or widely disseminate revised regulations and standards with the private health sector.
> Clinical training and updates: Although donors invest millions of dollars to train MOH staff, very little is
allocated to private sector providers. Private provider also need to keep up with technology, new
treatments and products and other advancements.
4.8 The Poverty Penalty
As a result of how decision are made and acted upon, the poor are penalized by not having access to an
efficient and equitable health system. As the prior sections revealed, depending on the illness, the consumer
– usually a mother taking care of a sick child – will first resort to self-medication, purchasing some form of
medication at a drug shop or kiosk located in her community. This is the mother’s first experience in the
health system and her first out-of-pocket payment to treat her child.
Usually, the substandard “drugs” do not successful treat her child’s illness, and the child’s health worsens.
The mother then decides, without conferring with her husband because all decisions related to the children
are within her purview, to consult an informal provider in her community. She visits the traditional healer for
a variety of reasons – convenience, trust and cost. Indeed, the mother cannot afford to pay the consultation
fee at either private or public health facility but the informal provider offers flexible payment terms. This is the
second time the poor mother has to pay to treat her increasingly sick child. The low quality and substandard
medication received from the informal provider often results in the child getting sicker.
As the illness progresses, the mother decides to see a trained health provider and for the first time enters
into the formal health sector. At this point, the mother may first go to a public facility. But she will pay yet
again for an administrative fee and purchase of drugs at a private pharmacy because the public facility does
not have the prescribed drugs in stock.
In severe cases, however, the mother will go directly to a private provider. In this case, she will have to
consult with her husband or other important male figure in the household because of the cost implications.
Depending on how the illness progresses and cost of treatment, the mother will bounce between the public
and private sectors several times until her child is, hopefully, successfully treated. Under this scenario, the
mother has to pay each time she interacts with a healthcare providers, driving the cost even higher to treat
one episode of illness. Because she is poor and cannot directly access affordable healthcare from a
trained provider in the first place, the mother and her child are penalized by the health system.
Working poor’s health seeking behaviour has significant financial implications. The research revealed that
the poor have to interact with the health sector more times than their wealthier counterparts, increasing the
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cost with each encounter. Not only do the poor pay out-of-pocket, they incur other non-monetary costs such
as increase in illness severity, length of illness episode and economic losses due to extended illness. The
net effect is a “poverty penalty”
The fact that the working poor pay out of pocket for each time they seek health care indicates that there are
opportunities for the private sector to minimize the number of interactions the patient has with the health
system and reduce the poverty penalty for the working poor.
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5 Policy Recommendations
With many African countries, such as Kenya, with worsening poverty and health outcomes, it seems
ineffective to entirely charge the government with the responsibility of health care for all its citizens. The
private sector in health has a role to play in improving health outcome especially among the poor. The study
was guided by the following research questions and the findings help inform potential private sector
interventions that will benefit the working poor.
> Who are the working poor in Kenya and what is their profile?
> What are the provider preferences for health care consumers within the PSP4H programme’s target
population?
> What are the health seeking behaviours of health care consumers within the PSP4H programme’s target
population?
> Are the health care consumers within the PSP4H programme’s target population willing to pay for certain
health services and products and to what extent do they have the ability to pay for those products and
services?
Smith and colleagues outline several ways in which interventions can be designed to increase coverage of
services, improve quality and control costs through the private sector. Table 6 describes various
opportunities and approaches for working with PSPs in the Kenyan market.
Table 7. Matrix of identified strategies to working with PSP for the poor Intervention objective
Interventions geared towards policy makers
Interventions geared towards providers
Enabling consumers and their representatives
Increase coverage of products and services with a public health benefit which are affordable for the poor
Strategy 1
Lower policy, regulatory and fiscal barriers
Remove barriers to private sector entry to market
Liberalize scopes of practice for key health cadre in private sector
Strategy 2
Recruit and network pharmacies into retail networks
Strategy 3
Recruit PSPs into an accredited network for specific health services with a public health benefit
Strategy 4
Contract with PSPs for packages of essential health care
Strategy 5
Market private sector services among priority target groups
Strategy 6
Introduce demand-side financing to remove economic barriers for priority target groups
Limit harmful practices and improve technical quality of care among PSPs
Strategy 7
Enact and enforce quality standards
Strengthen and enforce provider / facility licensing
Better integrate private sector in quality supervision
Strategy 8
Provide training supports and incentives to PSPs to conform to good practice norms
Strategy 9
Enact consumer protection law and raise awareness of consumer rights
Strategy 10
Increase consumer’s knowledge thru community education campaigns
Make PSP services more affordable
Strategy 11
Publish PSP prices
Encourage price minimums for priority services
Use insurance and contracting to influence prices
Strategy 12
Organize PSPs into group practices, insurance schemes and contracting
Strategy 13
Publish information to users on maximum permitted prices
The qualitative research reinforces the growing knowledge of the private sector role in delivering services to
the poor in Kenya. Although the private health sector face many challenges in serving this target group, they
are keenly interested in expanding their services to reach more clients – even the poor. Moreover, the
research shows that in many cases, the private sector is the provider of choice. Yet price makes access to
private facilities and providers unattainable.
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The research revealed several opportunities to expand the private sector role while improving the quality and
affordability of their services to benefit the poor. The qualitative study will guide the PSP4H programme as
they enter into the design phase to develop partnerships with private providers that will reach the working
poor in Kenya.
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7 Annex 1: Tools
Stakeholder Interview Guides Target audience There will be 3 categories of stakeholders.
1. The beneficiaries – the demand side (the poor) 2. The investors – the supply side 3. Policy environment players
Research Questions and Hypotheses
a) Beneficiaries 1. Is it commercially viable for private-for-profit and informal sector providers to offer quality,
affordable health services and products to poor customers and clients? Which products and services?
2. What incentives (financial and non-financial) motivate (encourage, facilitate) private-for-profit and informal providers to:
a. Enter into certain markets (supply chain, different health areas, etc.) b. Serve specific consumer groups (poor)
3. What factors enable private providers (formal and informal) to stay in these new markets and to expand services/products to the poor customers and clients?
4. What enabling factors (e.g. training, licensing, franchising, task-shifting) contribute to increasing quality and affordability of private sector health services and products delivered to the poor? (perverse outcomes or unanticipated outcomes?)
5. What are the characteristics and main drivers of the human health pharmaceutical supply chain, overall and particularly the parts of it which reach the poor? How has it changed in recent years?
6. Why is the supply chain the way it is? How does it differ from that for comparable products (such as agricultural chemicals for small farmers) and from neighboring countries?
For-profit service providers and shop-keepers selling medicines will find it commercially viable to offer
better quality care and products to their poor customers/clients.
It will be possible to identify incentives which persuade for-profit providers and
shopkeepers selling medicines to change their business practices in ways which benefit
poor people, and which can be sustained by the market after interventions have ended.
Players in the commercial supply chain will find it is commercially viable to make changes which will
benefit the poor people who buy their products.
It will be possible to identify incentives which persuade players in the commercial supply chain to change
their business practices in ways which benefit poor people, and which can be sustained by the market
after interventions have ended.
Improvements in the market for skilled health personnel (e.g. training, licensing, franchising, task-
shifting) which in theory should benefit poor people will actually have an impact on the quality and value
for money which poor people get in the for-profit market.
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b) Investors and Policy Environment
7. How active in this market are shop-keepers (formal and informal) selling medicine and for-profit health care providers? What are their qualifications and employment history? How does this vary by location and other factors, and how has it changed over recent years?
8. Why do for-profit providers behave the way they do? And how does their behaviour vary by type of client/patient, by health condition and other factors?
9. What is the extent of ‘dual practice’ (government health workers who also practice privately)? What are the drivers of this? How has it changed in recent years?
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Beneficiaries – FGD guide
Introduction
Please identify a private setting for the FGDs. I would like to thank each of you for agreeing to be a part of this focus group discussion. My name is ………………. . I will be leading the discussion session. My colleague here is called …………………; will help by taking notes about the discussion. We also request you to allow the session to be audio-taped so that we do not miss writing down any of the ideas. The purpose of conducting this discussion is to know your views in health care seeking patterns. The information collected will be useful in helping to understand how communities utilize various providers in health care. This will help the Ministry of Health and other stakeholders to plan effectively. There are no wrong or right answers. Please be assured that your personal details or what you say as a person will not be used at any time. What you say is therefore confidential and anonymous. We will ensure confidentiality with regard to all the information discussed and in particular, the information in the tapes will be destroyed after analysis. This discussion will also be anonymous – your names will not be recorded in the notes; rather we shall assign codes to the names. You are therefore encouraged to participate actively and to feel free during the discussion.
Do you have questions at this point about this discussion? Ask each participant to introduce himself or herself in turn. After the introductions, open up the discussion by asking the questions below. Project introduction: – exploring innovative approaches that will lead to improved health outcomes for the poor. This will be implemented through the private sector. Inclusion criteria – We are talking to different stakeholders in the private health sector and we think you might be in a position to provide us with information that will assist us to create the products and services that will benefit the poor. Participation to the discussion is voluntary and the information gathered here will be
Date of discussion: Moderator:
Venue : Note-taker:
Time start: No. Participants at start:
Time stop: No. Participants at stop :
Catchment site for FGD/facility County:
Participant Interview Number Gender (M/F)
Age Highest Level of Education
occupation family size
1
2
3
4
5
6
7
8
9
10
11
12
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confidential. There is no right or wrong answer and everything you tell us will be appreciated. The discussion will take about 45minutes to 1 hour. Target Audience: Working poor from urban and rural areas/men and women/married with children and single Guide Questions: 1. What kind of health problems do you or a member of your family face? (List)
Which of these are the most important? (List top five) (Probe for severity, frequency and how wide spread)
2. What do you do when you are feeling unwell/sick with XXXXX (insert priority illness identified
above)? (Probe for different scenarios - e.g. self-treat, go to formal healthcare provider, go to a tradition
healer/friend) What do you do when a member of your family is feeling unwell or is sick? (Probe for different scenarios - e.g. self-treat, go to formal healthcare provider, go to a tradition
healer/friend)
3. Where do you or your family members most often go for treatment? (Probe for the different sources of healthcare provider and facility level) - Government health facility (probe for type of facility-hospital, clinic, and health post) - Faith-based facility (probe for type of facility-hospital, clinic, and health post) - Non-government/foundation/charity (probe for type of facility-hospital, clinic, and health post) - Private pharmacy, drug shop - Traditional healer
-Other Focus: What drives the choice made for care seeking?
4. Why did you use the XXXXXXXXX (insert the type of provider/facility level)?
(Probe for reasons such as cost, distance, quality of services, convenience, provider attitude, personal preference)
5. Are there illnesses that you don’t seek treatment for? Which ones? Why?
6. Who makes the decision in your household to go seek treatment?
(Probe for description of the individuals involved, when the illness is discussed, who makes the final decision?)
7. Do you pay for the services you receive in the public sector? If so, a. Which services do you pay for?
(Probe for the type of services e.g. maternity, FP, under-fives, lab services etc.) b. How much do you pay?
(Probe for prices (or estimate) for different types of services) c. How do you pay for the service?
(Probe for mode of payment e.g. cash, insurance, kind, installments, reimbursement, etc.) d. How much would you be comfortable paying? (probe for amount) e. Which services don’t you pay for? Why? E.g. offered free.
8. Do you pay for the services you receive in the private sector? If so,
a. Which services do you pay for? (Probe for the type of services e.g. maternity, FP, under-fives, lab services etc.)
b. How much do you pay? (Probe for prices (or estimate) for different types of services)
c. How do you pay for the service? (Probe for mode of payment e.g. cash, insurance, kind, installments, reimbursement, etc.)
d. How much would you be comfortable paying? (Probe for amount)
e. Which services don’t you pay for? Why? (E.g. offered free, included in health insurance, etc.)
9. On average, how much do you pay for health services per month?
Approximately, how much does this XXX (insert amount) represent as a percentage of your
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total household income? 5 %, 10%, 20%? Are there times when you do not seek treatment because you cannot afford to? How often
does this occur? FOCUS: Are there any other circumstances other than cost that makes you not to seek
treatment? (Quality, provider behavior etc) What do you do in such circumstances?
9. Generally, where do people purchase their medicines in this community?
(Probe for healthcare professional, pharmacy, drug store, traditional healer, other?) a. Why did you use these facilities? XXXXXXXXX (insert the type of facility)?
(Probe for reasons such as availability, cost, convenience (distance, hours, days open), availability of health professional, provider attitude)
b. What drugs/medicines do they purchase most frequently? c. On average how much do people pay for medicines per month? d. Approximately, how much does this XXX (insert amount) represent as a percentage of your total
household income? 5%, 10%, 20%? e. Are there times when people do not buy drugs because you cannot afford to? f. Under what circumstances? g. How often does this occur?
10. In your opinion, what do people consider to be quality health services?
(Probe different characteristics: -Convenience (distance, hours) -Short waiting time -All services under one roof -Cleanliness (water, power, sanitation) -Friendly provider/friendly environment -Qualified staff (education, training, licensed by government) -Availability of drugs -Adequately equipped (water, electricity, etc. -Other
11. To make health care better for you and your family, what do you think should be done to improve
your experience in health services? Do you have any questions for us about this discussion or this study?
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Investor – In-Depth Interview Guide PART A: GENERAL INFORMATION
Name of respondent (Optional)
Occupation/business type
Age (Years)
Gender:
Time interview started:
Time interview ended:
Name of note taker:
Name of interviewer:
County
Script code:
Project introduction – exploring innovative approaches that will lead to improved health outcomes for the poor. This will be implemented through the private sector. Inclusion criteria – We are talking to different stakeholders in the private health sector and we think you might be in a position to provide us with information that will assist us to create the products and services that will benefit the poor. Participation in the discussion is voluntary and the information gathered here will be confidential. There is no right or wrong answer and everything you tell us will be appreciated. The discussion will take about 45minutes to 1 hour. Target Audience: Healthcare providers and business owners, rural/urban providers, different facility levels (hospital, clinics, diagnostic labs, pharmacies), different segments in private sector 1. Can you please provide a general description of your business/ practice
a. What is the nature of your business? (Probe: strategy, positioning, uniqueness, etc) b. How long have you been in business? c. What types of health services/products do you offer? d. Do you have specialized services? (Probe for maternity, GBV, psychiatrists) Why this services? e. How do you market your services to your potential clients? f. How many clients/customers do you serve? (per day? Month? etc)
2. Now we would like to ask you some basic questions regarding your facility
a. Do you own or rent this facility? b. What type of facility is this (dispensary, health center, pharmacy, nursing home, hospital, other) c. Is this health facility classified as private for-profit, FBO, NGO, Other? g. Do you have more than one facility? If so, where are they located? (Probe for satellite clinics and
franchises) h. How many hours a day is your facility(ies) open? (Probe: Evening, overnight, 24 hours, weekends,
etc) i. How many days a week is your facility(ies) open?
3. How many staff do you employ? What cadres of staff do you have working for you? (Probe for specialists, medical officers, clinical officers, registered nurses, pharmacists, pharmtechs, lab technologist, others)
4. Can you please provide an idea of prices for your products/services a. What determines your pricing? (probe: (e.g. actual costs, industry practice, what competition
charges, regulation and licensing, how?) b. Is there a variance in pricing for the same service for special groups? (Probe if the reduce/exempt
charges because of inability to pay, vulnerable population group, etc.) c. For the services you do not charge for, how do you recover your cost? d. Do you have a price list available for your clients to see?
5. Can you describe what type of clients you work with?
Probe e.g. geographic, socio-economic, gender a. How do your clients pay for products/services? (e.g. Drugs, Lab test, etc)
(Probe for cash, voucher, installment, and insurance) For clients who mention insurance probe for NHIF, micro-insurance & private insurance)
b. Do you offer credit for your services?
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c. In your opinion, do your patients consider these prices expensive? d. How do they compare to similar public services?
6. What internal challenges have you encountered in delivering healthcare services/products? Have you encountered any of the following challenges?
a. Lack of facilities / space b. High cost of equipment c. Lack of skills (provider) d. Poor returns e. Client inability to pay f. Unavailability of material/supplies g. Lack of awareness by clientele h. Other? (explain)
7. What external challenges do you encounter in running your healthcare business?
a. What types of licenses are you required to have? (Probe for professional or business licenses or any other and their availability)
b. Are you fully licensed? c. Are regulations on the establishment of private practices overly burdensome? d. Do they prevent private practitioners from establishing practices? e. Are there regulatory requirements that unnecessarily raise your costs? What are these? f. Do you view the existing regulations as fair and fairly administered? (probe: corruption) g. Do you think there are providers who compete unfairly with you because they are not properly
regulated? If so, who? 8. How do you finance your business/ practice?
a. What is your source of equity/startup capital? (family, savings, donors) b. Do you use credit? What is the source of the credit? (Probe: Bank loan, sacco, family, donors) c. Under what conditions do you obtain credit? (Probe: interest rates, collateral/security) d. Are micro-lending programmes targeting health care providers? e. Do you receive donor funds? If so, for what activities? f. Do you have unserved financing needs to expand your business? If so, which ones?
9. Is there a need for upgrading specific management skills for your business?
a. Financial skills? b. Marketing and promotion? c. Medical records? d. Information management system? If yes, do you apply the data you collect to better manage your
health business? e. Other (explain)
10. What are your major cost components?
(Probe – labor, drugs, lab tests, other) a. How would you lower cost of the products/services that you provide without compromising the
quality? b. How would you increase the quality of your products/services without increasing the costs?
11. Do you collaborate with the public sector?
(Probe for training, financial aid, supplies, contracting, send data to the public health information system, referral system, other?)
a. How important is the collaboration to the success of your business? b. Do you face any challenges in these collaborations? Which ones? c. How do you think such collaborations can be improved further? d. Do you think the private health sector could serve a portion of those who now rely on the Ministry of
Health for most of their services? e. Would you want to expand to serve such a population? What would it take to expand into this
market? f. From your perspective, how open is the government and/or Ministry of Health to working with the
private sector? g. Are there parts of the market that are attractive/not attractive to you because of the public sector
services? (Probe: maternity, U5s, family planning, diagnostics,)
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12. Do you see opportunities to expand your business/service? What do you see as potential areas
for expansion and improvement? a. New markets (geographical, target group) b. New products c. Do you have specific ideas/recommendations/plans?
13. How do you give and receive (health) information? (Probe for channels radio, TV, newsletter, email, brochures, posters, mhealth, ehealth, etc.)
a. How do your clients find out about you? b. What is your most preferred channel of getting/receiving health information?
Do you have any questions about this project or interview?
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8 Annex 2: Poverty screening tool
For all questions, please indicate the score by cricking appropriate options provided. If housheold/indiviudal
poorest will score 12 out of posibel 36 Maximum scores. Observe and ask the quetsions.
Domain Indicator Score
Housing Temporary housing made of mud or cardboard/papers 1
Semi permanent housing made of cement mud or wood or iron sheet 2
Permanent house made of brick or stone 3
House space One small room shared with other family 1
Two small rooms not sharing with other people 2
More than two rooms with additional space 3
Rental status Pay rent up to KES 500 1
Pay rent above 500 2
Do not pay rent/own house/shack 3
Source of water
Free, untreated water from river or spring 1
buy water from community tap or well 2
private water tap or well 3
Fuel for cooking Firewood or sawdust /straw/animal dung 1
charcoal or kerosene 2
electricity/gas 3
Security No doors /windows 1
Wooden doors or windows 2
Steel doors or watchmen 3
Garbage collection scattering 1
paper garbage bags 2
paid garbage collection 3
Sanitation bush/flying toilet 1
community pit latrine 2
private pit latrine /flush toilet 3
Daily income of HH
Less than KES 100 Per day 1
100-199 KES Per day 2
200-500 per day 3
average number of meals per day
one meal or less a day 1
more than one but less than three meals a day 2
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three meals or more 3
access to health services
home base care/herbal medicine 1
public hospital 2
private hospital /clinic 3
Type of work Daily irregular work (Manual or other) 1
Regular-factory worker/farm worker /small trader 2
business man/Own large business 3
total score
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Annex 3: Thematic Framework
Introduction
The thematic framework is presented here is based on an initial immersion of the data from seven sites.
These included in depth interviews as well as focus group discussions (FGDs) with various categories of
actors. The process of data collection was anchored on the broader programme objectives of the Private
Sector Innovation Programmeme for Health (PSP4H) . They include:
> Assessing and defining who are the poor in Kenya and to better understand their provider preferences,
their health-seeking behaviour, and their willingness and ability to pay for certain health services and
products
> Exploring under which circumstances does the private health sector deliver health services and products
to lower income groups, determining if these services and products are of quality and affordable, and
concluding if the private health sector services and products actually reach the poor
> Assessing the Kenyan health market and sub-sectors to identify and pilot appropriate pro-poor
interventions by the private health sector and to conduct action research to establish if the private health
sector can deliver quality, affordable health services that reach the poor
> Sharing the lessons learned from the different pro-poor health market interventions with Kenyan
stakeholders as well as international practitioners in public health working in developing countries
> This study aimed to address mainly objectives 1 and 2 stated above. The main research questions are:
> Who are the poor in Kenya, what is the profile for the poor?
> What are the provider preferences for health care consumers within the PSP4H programme’s target
population
> what are the health seeking behaviours of health care consumers within the PSP4H programme’s target
population
> Are the health care consumers within the PSP4H programme’s target population willing to pay for certain
health services and products and to what extent do they have the ability to pay for those products and
services?
The guides were developed with this idea in mind. The focus was on two categories of participants; the
beneficiaries – the demand side (the poor) and the investors – the supply side. The guide was designed to
address the question as to whether it is commercially viable for private-for-profit and informal sector
providers to offer quality, affordable health services and products to poor customers and clients? The
questions focussed on incentives (financial and non-financial) motivate (encourage, facilitate) private-for-
profit and informal providers to, what factors enable private providers (formal and informal) to stay in these
new markets and to expand services/products to the poor customers and clients? Among clients the
focus of the guide was on health care seeking patterns, decision making dynamics at household level, and
cost of services. The guide also focussed on the ability to pay and preferences
> The coding framework therefore utilises two main approaches: inductive approaches where two
researchers independently read through the transcripts and developed a set of themes that emanated
from the responses. The emerging themes were then linked with the guide that was used a priori. The
coding framework was developed from reading the set of interviews from seven sites as indicated in table
1 below. A tentative thematic framework was developed for sharing. The final thematic framework will
be finalize after all data have been coded. This document summarizes the initial set of themes used for
this analysis
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Table 3: list of transcripts read to develop the thematic framework Site FGD IDI
Busia 2 FGDs with women under 25 and above 1 FGD with health provides
5 IDIs 2 with pharmacists and 3 with private sector investors
Garissa 1 FGD 4 IDIs;
Isiolo 3 FGDs: 2 with women, 1 with health workers
3 IDIs
Kiambu 1 FGD 3 IDIS
Kisumu 1 FGD 1 IDI
Mombasa 1 FGD
Nyamira 1 FGD 1 IDI
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THEMATIC FRAMEWORK 1.0 Common medical problems encountered 1.1 Common illnesses 1.1.1 Type of illnesses 1.1.2 Top diseases 1.1.3 Illnesses that people do not seek care 1.1.4 Preferred cost of care seeking
1.2 Care seeking patterns 1.2.1 Sources of care 1.2.2 Care seeking dynamics 1.2.3 Reasons for choice of care 1.2.4 Decisions making dynamics 1.2.5 Health care expenditure 1.2.6 Reason for not seeking care 1.2.7 services offered for free 1.2.8 sources of medicines
1.3 Challenges of service provision 1.3.1 Supply of products 1.3.2 Side effects of FP methods 1.4 Facility Details
1.4.1 History of facility 1.4.2 Services offered 1.4.3 Marketing strategies 1.4.4 Price determination 1.4.5 Staffing 1.4.6 Financing strategies 1.4.7 Client Load 1.4.8 Characteristics of clients served 1.4.9 Expansion strategies 1.4.10 Cost of services 1.4.11 mode of payment of services 1.4.12 facility upgrade 1.4.13 facility type 1.4.14 process of licensing 1.4.15 skill set needed
1.5 Challenges faced by private sector providers 1.5.1 Financial 1.5.2 Licensures 1.5.3 Low sales 1.5.4 Competition 1.5.5 Staff turn over 1.5.6 Work load 1.5.7 Space 1.5.6 Regulation 1.6 Mechanisms of involving private sector for poor
1.6.1 Subsidies 1.6.2 Waiver 1.6.3 Financial incentives 1.6.4 Non financial incentives 1.7 Qualities of a good health services 1.7.1 Holistic services 1.7.2 Waiting times 1.7.3 Convenience 1.7.4 Availability of supplies
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1.7.5 Trained staff 1.7.6 Positive provider behavior 1.7.7 Credit services 1.7.8 Diagnostic services 1.7.9 Environment 2.0 Facilitating factors to use of private sector
2.1 Cost of access 2.2 Inadequate Human resources in public sector 2.3 Long waiting times 2.4 Equipment and supplies 2.5 Specialised diagnostics 2.6 Private provider behaviours 2.7 Geographical location 2.8 Convenience 2.9 corrupt practices in public facilities 2.10 confidentiality
3.0 Role of devolved government 3.1 Divisions in health sector
3.2 County roles
4.0 Linkages between private and public government 4.1 regulations 4.2 Supportive supervision 4.3 Referrals 4.4 Coordination 4.5 stakeholder forums 4.6 specific services 4.7 Provision of supplies 4.8 Training
5.0 Factors influencing increasing quality of services 5.1 Training 5.2 licensing 6.0 Challenges of private sector
6.1 Business orientation 6.2 regulations 6.3 expansion/Space 6.4 unqualified providers 6.5 competition 6.7 Licensure 6.8 price fluctuations 6.9 Type of clients
7.0 Functioning of private sector 7.1 dual practices 7.2 merits and demerits of dual practices 7.3 Flexibility of service provision 7.4 cost containment 7.5 Credit facilities 7.6 opening and closing hours 7.7 Coverage 7.8 Payment of services
8.0 Communication channels 8.1 Print media 8.2 audio/visual media 8.3 workshop/seminars 8.5 T-shirts/caps 8.6 posters
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8.7 preferred channels
9.0 Recommendation 9.1 Recommendation for improving collaboration 9.2 Recommendation for improving health care