Analyzing the equity of public primary care provision in Kenya: variation in facility characteristics by local poverty level

Abstract

Introduction: Equitable access to health care is a key health systems goal, and is a particular concern in low-income countries. In Kenya, public facilities are an important resource for the poor, but little is known on the equity of service provision. This paper assesses whether poorer areas have poorer health services by investigating associations between public facility characteristics and the poverty level of the area in which the facility is located.

Methods: Data on facility characteristics were collected from a nationally representative sample of public health centers and dispensaries across all 8 provinces in Kenya. A two-stage cluster randomized sampling process was used to select facilities. Univariate associations between facility characteristics and socioeconomic status (SES) of the area in which the facility was located were assessed using chi-squared tests, equity ratios and concentration indices. Indirectly standardized concentration indices were used to assess the influence of SES on facility inputs and service availability while controlling for facility type, province, and remoteness.

Results: For most indicators, we found no indication of variation by SES. The clear exceptions were electricity and laboratory services which showed evidence of pro-rich inequalities, with equity ratios of 3.16 and 3.43, concentration indices of 0.09 (p<0.01) and 0.05 (p=0.01), and indirectly standardized concentration ratios of 0.07 (p<0.01) and 0.05 (p=0.01). There were also some indications of pro-rich inequalities for availability of drugs and qualified staff. The lack of evidence of inequality for other indicators does not imply that availability of inputs and services was invariably high; for example, while availability was close to 90% for water supply and family planning services, under half of facilities offered delivery services or outreach.

Conclusions: The paper shows how local area poverty data can be combined with national health facility surveys, providing a tool for policy makers to assess the equity of input and service availability. There was little evidence of inequalities for most inputs and services, with the clear exceptions of electricity and laboratory services. However, efforts are required to improve the availability of key inputs and services across public facilities in all areas, regardless of SES.

Figure 1

Proportion of households above the poverty line by (a) province, (b) facility type, and (c) remoteness (Box plots represent 25th to 75th percentiles, diamonds represent medians, and whiskers represent minimum and maximum values). Note: Municipal areas included districts of Kilindini (Coast province), Nairobi West (Nairobi province), and Kisumu East (Nyanza province). NE=North Eastern; RV=Rift Valley.