Effects of new service charges on attendance at rural health facilities in Kenya

Abstract

Kenyans have long enjoyed free outpatient health care at government facilities while paying for admission and for child delivery. In December 1989 user charges were introduced also for out-patient care at hospitals and health centres. This before-and-after study of one rural hospital, two health centres and two dispensaries in rural Kenya shows major and statistically significant early drops in outpatient attendance at the hospital (28%) and at the health centres (50 and 43%) followed by a slow increase during the following months. There was a modest, not significant, decline also at the dispensaries (14 and 7%) and in demand for services unaffected by the new fees and charges.

PIP: User charges were introduced December 1989 in Kenya for outpatient care at hospitals and health centers. Prior to this, Kenyans enjoyed free outpatient health care at government facilities, but paid for admission and child delivery. Escalating health care costs and weak economies are forcing widespread changes in how governments finance their health care systems. User charges ideally generate revenue, while reducing superfluous service consumption. 35% of all health care provided in Kenya, however, was from fee-for-service nongovernment organizations, private medical facilities, and traditional practitioners. The concept and practice of paying for health services were therefore not alien to Kenyans even before 1990. The authors compare client attendance and service utilization during December 1988-May 1989 with that for December 1989-May 1990 to assess the impact of the implementation of fees for services. Information was gathered from attendance records, staff interviews, and four patient focus groups for one rural hospital, two health centers, and two rural dispensaries. Outpatient attendance declined by 28% at the hospital and 50% and 43% at the health centers. Attendance recovered over the following months to 20-40% below baseline levels. Declines of 14% and 7% were observed for the dispensaries and in demand for services unaffected by the new fees and charges.