Elimination of user fees in primary healthcare facilities is one of the key policy considerations to address the critical issue of equity access to healthcare by the poor and vulnerable groups. According to Maina and Kirigia (2015), user fees introduced in many LMICs, Kenya included, in the 1980s have failed to achieve the objective of improving access to quality healthcare, especially by the poor and the vulnerable. The health sector in Kenya is mainly funded by the government through budgetary allocations and contributions from members of NHIF, the private sector and out-of-pocket (OOP), which enhance financial hardship (Government of Kenya, 2015).
Policy makers and other health experts should consider elimination of user fees for Public Health Care (PHC) services, especially during humanitarian crises, as a human rights issue (Inter-Agency Standing Committee, 2010). This is aimed at reducing the financial barrier to access to PHC services, especially for the most vulnerable and excluded groups in society. There is an emerging international consensus that access to PHC services is a critical element of any humanitarian health response for people affected by crises. User fees impede this access and cause suffering to the poor and vulnerable.
Abolition of user fees was announced by the President in 2013 and the Ministry of Health communicated the information downward through a circular. Despite this, a study by Maina and Kirigia (2015) revealed that at least 14 percent of people seeking healthcare at public health centres and dispensaries and 80 percent of those seeking care at faith-based facilities paid for some services received. The study also revealed that many public facilities charged patients Ksh10 or Ksh20 for registration/card books or were requested to buy the same from elsewhere before being provided with free health services. In addition, patients were sometimes asked to pay for some services, such as drugs for some illnesses, laboratory and injections to fill the gap caused by insufficient reimbursement of funds by the Ministry of Health. Some of the government’s initiatives to eliminate user fees in public healthcare facilities are discussed below:
Linda Mama, Boresha Jamii (Free Maternal Care Programme)
This programme was announced by the President in 2013 with the aim of removing maternity fees in public health facilities countrywide and ensuring pregnant women and their new-borns access quality and affordable healthcare. The programme was then launched in October 2016 followed by the signing of a Memorandum of Understanding (MoU) between the Government and the NHIF in February 2017. The Linda Mama programme is managed by NHIF. In a span of three years after the programme was launched, the number of women who delivered in public health facilities increased by over 400,000 as a result of making maternity services accessible by removing financial barriers (Government of Kenya, 2016b), reducing home deliveries.
A study by Calhoun et al, (2018) on ‘The effect of the policy to remove user fees on institutional delivery in population-based samples of women from urban Kenya’, found that the government’s move led to increased use of facilities by poor inhabitants.
According to the Government of Kenya (2019), normal deliveries in health facilities for the period 2014-2018 increased from 768,600 in 2014 to 938,900 in 2018. The second important mode of delivery was Caesarean section, which increased from 110,900 in 2014 to 155,100 cases in 2018, followed by assisted vaginal delivery which declined from 7,000 in 2014 to 4,000 in 2018. Breech delivery had a marginal increase from 8,900 in 2014 to 9,200 in 2018. Overall, the total deliveries increased from 895,900 in 2014 to 1,107,200 in 2018. Normal delivery was the leading mode of delivery, followed by Caesarean section and, lastly, breech delivery. The dominance of normal delivery may be attributed to the success of the Linda Mama Free Maternity programme. While these statistics look promising, it is important to note that about 14 women die daily in Kenya from pregnancy-related causes, such as severe bleeding, infection, hypertensive disorders, malaria, obstructed labour, diabetes, hepatitis and anaemia (Oketch, Angela et al., 2020:4-5).
The beneficiaries of the Linda Mama programme are pregnant women and new-borns for about one year. Both public and private health providers are contracted to provide services. The package includes services such as antenatal care (ANC), maternity deliveries and postnatal care (PNC), based on national guidelines (Government of Kenya, 2016b). In addition, the package includes both outpatient and inpatient treatment for conditions and complications during pregnancy, delivery or postnatal as well as treatment of the new-born within the stipulated one-year period.
These benefits are only available to registered mothers. All mothers who have not registered for NHIF Supacover are eligible. Once they register, they will have to wait for six months before accessing free maternity services − an avenue for delayed access to benefits of the programme and clearly exacerbates financial hardship.
Under-18 pregnant girls can register using their guardians’ identification documents. Mothers registered under the programme are issued with a Linda Mama Card. According to an investigative study by Oketch et al. (2020), issuance of this card has delayed in most county hospitals visited while services were not being offered optimally due to lack of adequate funds. There appears to be a trend of budget reductions; for example, in 2016-17 financial year, the government had set aside Ksh6 billion for the Linda Mama programme but the National Treasury later reduced it to Ksh4.5 billion. Budget allocation for the programme has since dropped to Ksh3.5 billion, further putting hospitals in a financial crisis that requires urgent intervention.
Although there have been gains attributed to Linda Mama programme, such as an increased number of registered women seeking delivery services, and reduction of maternal and child mortality rates, the management and implementation of the programme has been faced with challenges, as highlighted below:
- Lack of awareness among potential women members. A countrywide awareness campaign is required to sensitise both health workers and potential beneficiaries of the programme.
- Lack of funds. Public hospitals experience late disbursement of funds and lower rate of reimbursement for deliveries from NHIF (Oketch et al., 2020). This has forced many hospitals to charge maternity patients for postnatal care − further diminishing the gains of the programme. Under the programme, normal delivery reimbursement rate for public health and primary health facilities is Ksh2,500. In other hospitals, the rate is Ksh5,000. Late reimbursement has, however, been blamed on the institutional framework where money is disbursed early by NHIF but delayed at the county appropriation level.
- Inadequate infrastructure. Linda Mama programme attracted many women who were previously excluded from maternity health services by high user fees, thus putting a strain on available equipment and infrastructure. In some hospitals, the situation is so bad that up to three mothers share a bed (Oketch et al., 2020). This not only exposes beneficiaries of the Linda Mama programme, and the health workers, to communicable disease (CDs) and other health risks, but also compromises the quality of services provided.