3.3.1 Availability of drugs
NHIF members stated that they would select facilities where drugs were available. Drugs were considered to be the bare minimum criterion given the price of obtaining the drugs in private pharmacies and the fact that often people could fall sick when they don’t have money to buy drugs out-of-pocket.
“It is better you use ten shillings to go and ten shillings to come back and you get drugs, so [I am] saying, availability of drugs is a very important issue.” FGD 4 Nyeri County – Rural“Drugs are a must. You can go there and get a prescription and yet you only had bus fare. When you go home without drugs, you will continue to be sick.” FGD 3 Nyeri County – Urban
Distance from the household to the facility
NHIF members highlighted distance to be an important factor influencing their choice of an outpatient provider. Importantly, NHIF members indicated a preference for facilities that were not longer than 5KM from their households to reduce both the suffering in moving from a household to a facility when ill and the associated costs for travelling to a far facility. However, some members, especially in rural settings highlighted a willingness to travel to a far healthcare provider as long as they would obtain drugs.
“Distance to the facility is also very important. Imagine you need urgent care and the facility is very far, you will be in trouble. It’s better a facility that is close, maybe three or five Kilometres. Again, the far the facility is, you have to pay for transport to get there” FGD 4 Nyeri County – Rural
Waiting time at the facility until consultation
Although the availability of drugs and distance to facilities were often ranked by NHIF members as the top two factors influencing their choice of an outpatient healthcare provider, NHIF members also indicated a high preference for the waiting time at the facility. Waiting time was defined as the time a patient would wait in line at the facility until they get a consultation. Notably, even though respondents indicated an acceptable waiting time of up to 3 hours, respondents in rural areas were more likely to state longer waiting times even up to five hours than their counterparts in FGDs conducted in urban areas. A key reason for this was as a result of fewer NHIF-contracted outpatient providers in rural areas than in urban settings where several NHIF-contracted private facilities complimented public facilities in delivering care and were available for selection.
“Sometimes you will find that the hospital is full to capacity, long queues so before you get out of there, you will have lost a lot of time, it will be a difficult time for you.” FGD 1 Makueni County – Rural
The attitude of the health workers
NHIF members indicated other factors associated with the quality of care received within facilities. The attitude (courteousness) of the healthcare worker was one of the highlighted factors. Respondents expressed issues around the level of respect accorded to them by healthcare workers some complaining about issues of abuses and the lack of proper explanation of required procedures. NHIF members expressed a preference for facilities where the staff would talk to them nicely and with respect as opposed to facilities where the staff were rude and used abusive language.
It is how the doctors receive you, how they talk to you, the nurse calls you as if you are [not human] that public relation should be very improved, public relation for these people. FGD 4 Makueni County – Urban“You can go there and see how they serve people, even how the nurses talk to patients, they are very harsh, and sometimes they irritate you even before you are treated. I look for a hospital which I have gone to before and I have seen them serve people well.” FGD 4 Nyeri County – Rural
The cadre of staff seen during consultation
The cadre of healthcare workers seen during the consultation was also an important factor. In urban settings particularly, NHIF members indicated the need to see a Medical Doctor/Officer rather than a clinical officer or nurse. Respondents expressed the need for a more experienced health worker cadre for consultation and therefore a more senior medical personnel would be ideal. However, in rural areas, even though this factor was also highlighted, it was not a major contributor to the choice.
“I think medical doctors are the most experienced staff and would treat me better than seeing a nurse.” FGD 4 Makueni county – Urban“I think all staff that are at the facility are qualified enough to provide care at that level. I wouldn’t mind seeing a nurse or clinical officer or medical doctor as long as they will treat me well and I would get the medication I need. I actually can’t tell the difference between a clinical officer and a medical doctor!” FGD 4 Nyeri County – Rural
Cleanliness of the facility
The cleanliness of a facility was another quality-related factor that influenced the choice of an outpatient facility among NHIF members. Cleanliness was defined around the cleanliness of the consultation rooms, facility floors and toilets. Members preferred facilities that were always clean especially the corridors, waiting areas, consultation rooms and hygiene facilities. Cleanliness of a facility was indicated to be important due to general view or hygiene reasons as well as the likelihood to get other infections, especially where a facility was not tidy enough.
“Even though there are other very important factors but the facility should be clean. Cleanliness is very important as it shows how the facility provides quality services or not.” FGD 1 Makueni County – Rural
Opening hours of the facility
As outpatient services do not involve admission, the opening hours of the facility was another important factor. Specifically, NHIF members highlighted a preference for facilities that were open 24 hours a day compared to those only open during the day. This was crucial as people could require care at any time even at night.
“I would choose a facility that is open 24 hours a day compared to one that is 12 hours a day. I can have a very bad headache at night and need urgent medical attention or drugs. It would be very bad if the facility is closed at night.” .” FGD 1 Makueni County – Rural
Table 2 summarises the factors and their levels as indicated from the focus group discussions with NHIF members.
Table 2: Summary of the factors and their levels that influence NHIF members’ choice of an NHIF-contracted outpatient facility