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International Journal for Equity in Health
Published in: International Journal for Equity in Health 1/2020

01-12-2020 | Care | Research

Examining user fee reductions in public primary healthcare facilities in Kenya, 1997–2012: effects on the use and content of antenatal care

Authors: Mardieh L. Dennis, Lenka Benova, Catherine Goodman, Edwine Barasa, Timothy Abuya, Oona M. R. Campbell

Published in: International Journal for Equity in Health | Issue 1/2020

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Abstract

Background

In 2004, The Kenyan government removed user fees in public dispensaries and health centers and replaced them with registration charges of 10 and 20 Kenyan shillings (2004 $US 0.13 and $0.25), respectively. This was termed the 10/20 policy. We examined the effect of this policy on the coverage, timing, source, and content of antenatal care (ANC), and the equity in these outcomes.

Methods

Data from the 2003, 2008/9 and 2014 Kenya Demographic and Health Surveys were pooled to investigate women’s ANC care-seeking. We conducted an interrupted time series analysis to assess the impact of the 10/20 policy on the levels of and trends in coverage for 4+ ANC contacts among all women; early ANC initiation and use of public facility-based care among 1+ ANC users; and use of public primary care facilities and receipt of good content, or quality, of ANC among users of public facilities. All analyses were conducted at the population level and separately for women with higher and lower household wealth.

Results

The policy had positive effects on use of 4+ ANC among both better-off and worse-off women. Among users of 1+ ANC, the 10/20 policy had positive effects on early ANC initiation at the population-level and among better-off women, but not among the worse-off. The policy was associated with reduced use of public facility-based ANC among better-off women. Among worse-off users of public facility-based ANC, the 10/20 policy was associated with reduced use of primary care facilities and increased content of ANC.

Conclusions

This study highlights mixed findings on the impact of the 10/20 policy on ANC service-seeking and content of care. Given the reduced use of public facilities among the better-off and of primary care facilities among the worse-off, this research also brings into question the mechanisms through which the policy achieved any benefits and whether reducing user fees is sufficient for equitably increasing healthcare access.
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Literature
1.
World Health Organization Regional Committee for Africa. Review of the implementation of the Bamako Initiative: Report of the Regional Director. Windhoek: World Health Organization; 1999.
2.
The World Bank. Financing health services in developing countries: an agenda for reform. 1987.CrossRef
3.
4.
Mwabu G, Manzia J, Liambila W. User charges in government health facilities in Kenya: effect on attendance and revenue. Health Policy Plan. 1995;10(2):164–70.CrossRefPubMed
5.
Matji M, Ts’oene P, Spencer A, Gertler P, Byrne D. Do user fees reduce the demand for health care? Insights and limitations of service statistics in Lesotho. In: Shaw RP, Ainsworth M, editors. Financing health services through user fees and insurance: case studies from sub-Saharan Africa. Washington: The World Bank; 1996. p. 67–83.
6.
Mwabu G, Ainsworth M, Nyamete A. Quality of medical care and choice of medical treatment in Kenya : an empirical analysis quality of medical care and choice of medical treatment in Kenya an empirical analysis. J Hum Resour. 1993;28(4):838–62.CrossRef
7.
Moses S, Plummer FA, Manji F, Bradley JE, Nagelkerke NJD, Malisa M. Impact of user fees on attendance at a referral Centre for sexually transmitted diseases in Kenya. Lancet. 1992;340(8817):463–6.CrossRefPubMed
8.
Mbugua JK, Bloom GH, Segall MM. Impact of user charges on vulnerable groups: the case of Kibwezi in rural Kenya. Soc Sci Med. 1995;41(6):829–35.CrossRefPubMed
9.
De Bethune X, Alfani S, Lahaye J. The influence of an abrupt price increase on health service utilization: evidence from Zaire. Health Policy Plan. 1989;4(1):76–81.CrossRef
10.
Waddington C, Enyimayew KA. A price to pay, part 2: the impact of user charges in the Volta region of Ghana. Int J Health Plann Manag. 1990;5(4):287–312.CrossRef
11.
Nolan B, Turbat V. Cost recovery in public health Services in sub-Saharan Africa. Washington: The World Bank; 1995.CrossRef
12.
Collins D, Quick JD, Musau SN, Kraushaar D, Hussein IM. The fall and rise of cost sharing in Kenya: the impact of phased implementation. Health Policy Plan. 1996;11(1):52–63.CrossRefPubMed
13.
Diop F, Yazbeck A, Bitran R. The impact of alternative cost recovery shemes on access and equity in Niger. Health Policy Plan. 1995;10(3):223–40.CrossRefPubMed
14.
Hecht R, Overholt C, Homberg H. How cost recovery can help rationalize the health care system: lessons from Zimbabwe. In: Shaw RP, Ainsworth M, editors. Financing health services through user fees and insurance: case studies from sub-Saharan Africa. Washington: The World Bank; 1996. p. 43–66.
15.
Creese AL. User charges for health care: a review of recent experience. Heal Policy Plan. 1991;6(4):309–19.CrossRef
16.
National Coordinating Agency for Population and Development (NCAPD) [Kenya], Ministry of Health, Central Bureau of Statistics, ORC Macro. Kenya service provision assessment survey 2004. 2005;.
17.
Ministry of Health. Kenya health sector referral strategy. 2014.
18.
Swamy G. Kenya: structural adjustment in the 1980s Kenya: structural adjustment in the eighties. World Bank; 1994.
19.
Abuya T, Maina T, Chuma J. Historical account of the national health insurance formulation in Kenya: experiences from the past decade. BMC Health Serv Res. 2015;15:56.CrossRefPubMedPubMedCentral
20.
Government of Kenya. Economic recovery strategy for wealth and employment creation 2003-2007. 2003.
21.
Chuma J, Musimbi J, Okungu V, Goodman C, Molyneux C. Reducing user fees for primary health care in Kenya: policy on paper or policy in practice? Int J Equity Health. 2009;8(1):15.CrossRefPubMedPubMedCentral
22.
World Bank Group. Sustainable health systems and fair financing for achieving universal health coverage in Kenya: a framework for support from the World Bank Group. 2014.
23.
Opwora A, Waweru E, Toda M, Noor A, Edwards T, Fegan G, et al. Implementation of patient charges at primary care facilities in Kenya: implications of low adherence to user fee policy for users and facility revenue. Health Policy Plan. 2015;30(4):508–17.CrossRefPubMed
24.
Onsomu E, Muthaka D, Mwabu G, Nyanjom O, Dutta A, Maina TM, et al. Public expenditure tracking survey in Kenya, 2012 (PETS-plus). Washington, D.C. and Nairobi: Futures Group, Health Policy Project and Kenya Institute for Public Policy Research and Analysis; 2014.
25.
Pyone T, Smith H, van den Broek N. Implementation of the free maternity services policy and its implications for health system governance in Kenya. BMJ Glob Heal. 2017;2(4):e000249.CrossRef
26.
Obare F, Abuya T, Matanda D, Bellows B. Assessing the community-level impact of a decade of user fee policy shifts on health facility deliveries in Kenya. Int J Equity Health. 2003-2014;2018:1–13.
27.
Singh K, Story WT, Moran AC. Assessing the continuum of care pathway for maternal health in South Asia and sub-Saharan Africa. Matern Child Health J. 2016;20(2):281–9.CrossRefPubMedPubMedCentral
28.
Chukwuma A, Wosu AC, Mbachu C, Weze K. Quality of antenatal care predicts retention in skilled birth attendance: a multilevel analysis of 28 African countries. BMC Pregnancy Childbirth. 2017;17(1):1–10.CrossRef
29.
Owili PO, Muga MA, Chou Y-J, Hsu Y-HE, Huang N, Chien L-Y. Associations in the continuum of care for maternal, newborn and child health: a population-based study of 12 sub-Saharan Africa countries. BMC Public Health. 2016;16(1):414.CrossRefPubMedPubMedCentral
30.
Anastasi E, Borchert M, Campbell OMR, Sondorp E, Kaducu F, Hill O, et al. Losing women along the path to safe motherhood: why is there such a gap between women’s use of antenatal care and skilled birth attendance? A mixed methods study in northern Uganda. BMC Pregnancy Childbirth. 2015;15(1):1–15.CrossRef
31.
Wang W, Hong R. Levels and determinants of continuum of care for maternal and newborn health in Cambodia-evidence from a population-based survey. BMC Pregnancy Childbirth. 2015;15(1):1–9.CrossRef
32.
Ensor T, Quigley P, Green C, Razak Badru A, Kaluba D, Siziya S. Knowledgeable antenatal care as a pathway to skilled delivery: Modelling the interactions between use of services and knowledge in Zambia. Health Policy Plan. 2014;29(5):580–8.CrossRefPubMed
33.
Adjiwanou V, LeGrand T. Does antenatal care matter in the use of skilled birth attendance in rural Africa: a multi-country analysis. Soc Sci Med. 2013;86:26–34.CrossRefPubMed
34.
Guliani H, Sepehri A, Serieux J. What impact does contact with the prenatal care system have on women’s use of facility delivery? Evidence from low-income countries. Soc Sci Med. 2012;74(12):1882–90.CrossRefPubMed
35.
Central Bureau of Statistics, Ministry of Health, ORC Macro. Kenya Demographic and Health Survey 2003. Calverton, Maryland: Kenya Demographic and Health Survey; 2004.
36.
Kenya National Bureau of Statistics (KNBS), ICF Macro. Kenya Demographic and Health Survey 2008–09. Calverton, Maryland: KNBS and ICF Macro; 2010.
37.
Kenya National Bureau of Statistics, Ministry of Health, National AIDS Control Council, Kenya Medical Research Institute, National Council for Population and Development, ICF International. Kenya Demographic and Health Survey 2014. Rockville, Maryland, USA: ICF International; 2015.
38.
World Health Organization. WHO Recommendation on antenatal care for positive pregnancy experience. Geneva: World Health Organization; 2016.
39.
Benova L, Tunçalp Ö, Moran AC, Campbell OMR. Not just a number: examining coverage and content of antenatal care in low-income and middle-income countries. BMJ Glob Heal. 2018;3(2):e000779.CrossRef
40.
Blencowe H, Cousens S, Oestergaard MZ, Chou D, Moller AB, Narwal R, et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet. 2012;379(9832):2162–72.CrossRefPubMed
41.
Blencowe H, Cousens S, Chou D, Oestergaard M, Say L, Moller AB, et al. Born too soon: the global epidemiology of 15 million preterm births. Reprod Health. 2013;10:1–14.CrossRef
42.
Linden A. Conducting interrupted time-series analyes for single- and multiple-group comparisons. Stata J. 2015;15(2):480–500.CrossRef
43.
Barasa EW, Maina T, Ravishankar N. Assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in Kenya. Int J Equity Health. 2017;16:31.
44.
Oluoch DA, Mwangome N, Kemp B, Seale AC, Koech A, Papageorghiou AT, et al. “You cannot know if it’s a baby or not a baby”: uptake, provision and perceptions of antenatal care and routine antenatal ultrasound scanning in rural Kenya. BMC Pregnancy Childbirth. 2015;15(1):1–11.CrossRef
45.
Magadi MA, Madise NJ, Rodrigues RN. Frequency and timing of antenatal care in Kenya: explaining the variations between women of different communities. Soc Sci Med. 2000;51(4):551–61.CrossRefPubMed
46.
Ochako R, Fotso JC, Ikamari L, Khasakhala A. Utilization of maternal health services among young women in Kenya: insights from the Kenya demographic and health survey, 2003. BMC Pregnancy Childbirth. 2011;11(1):4–9.CrossRef
47.
Dzakpasu S, Powell-Jackson T, Campbell OMR. Impact of user fees on maternal health service utilization and related health outcomes: a systematic review. Health Policy Plan. 2014;29(2):137–50.CrossRefPubMed
48.
WHO Antental Care Trial Research Group. WHO antenatal care randomized trial: manual for the implementation of the new model. Geneva: World Health Organization; 2002.
49.
Birungi H, Onyango-Ouma W. Acceptability and Sustainability of the WHO Focused Antenatal Care package in Kenya. Nairobi, Kenya: Frontiers in Reproductive Health Program, Population Council; Institute of African Studies, University of Nairobi; 2006.CrossRef
50.
Johnson FA, Frempong-Ainguah F, Padmadas SS. Two decades of maternity care fee exemption policies in Ghana : have they benefited the poor? Heal Policy Plan. 2016;31:46–55.CrossRef
51.
Hatt LE, Makinen M, Madhavan S, Conlon CM. Effects of user fee exemptions on the provision and use of maternal health services: A review of literature. J Heal Popul Nutr. 2013;31(4 SUPPL.2):67–80.
52.
Gwatkin DR, Ergo A. Universal health coverage: friend or foe of health equity? Lancet. 2010;10:2160–1.
Metadata
Title
Examining user fee reductions in public primary healthcare facilities in Kenya, 1997–2012: effects on the use and content of antenatal care
Authors
Mardieh L. Dennis
Lenka Benova
Catherine Goodman
Edwine Barasa
Timothy Abuya
Oona M. R. Campbell
Publication date
01-12-2020
Publisher
BioMed Central
Keyword
Care
Published in
International Journal for Equity in Health / Issue 1/2020
Electronic ISSN: 1475-9276
DOI
https://doi.org/10.1186/s12939-020-1150-8

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