DISCUSSION
Our study presents the level of awareness, experiences and factors that
influence NHIF members’ choice of an outpatient facility in Kenya. We
show that, first, while there is a good understanding of the NHIF
requirement to choose a facility, members from rural areas remain
largely unaware of the electronic approaches to choosing or changing a
facility.
While technology has been shown to improve the ease of choosing and
changing facilities in this study, it appears the approach to
communicating the changes, especially in a rural setting remains
wanting. While methods such as the media and the internet are mostly
used by NHIF to pass information, the rural setting population often
don’t have good access to media or the internet and thus such
information may not reach them. For instance, as of 2020, only 30% of
the population in Kenya was using the Internet 37.
Besides, a larger share of the population in Kenya is either not exposed
to media or exposed less than once a week 23 making
obtaining information passed by NHIF through such platforms a key
challenge. Besides, these findings align with a previous study where
respondents expressed the inadequate communication of the new benefits
package introduced by NHIF and even when communication was done, it was
unequally distributed across different citizen groups11.
Second, respondents also expressed concern regarding the lack of choice
for providers in rural settings due to the few facilities contracted to
offer outpatient services. These findings are similar to those from two
previous studies in Kenya that showed that NHIF contracting of
facilities has had an urban bias and the contracting process undermined
equity 11, 38. While the contracting process involves
an application for accreditation, inspection, gazettement and contract
signing, the process has been shown to undermine geographical access,
especially in rural areas and historically marginalized settings in
Kenya due to the rigorous nature of the requirements that leave out the
only available facilities that do not meet the conditions in the
marginalised areas 38. Besides, while the process is
initiated by the NHIF in the public sector, private providers
self-initiate the process of contracting which may explain the fewer
providers from the private sector even though the sector forms over 50%
of all providers in Kenya 21. Furthermore, providers
have expressed dissatisfaction with the provider payment rates and
mechanisms used by NHIF 39 which could further explain
the fewer providers willing to be contracted by NHIF.
Third, it is not surprising that the availability of drugs, distance
from the household to the facility and waiting time at the facility were
the three most important factors influencing NHIF members’ choice of an
NHIF-contracted outpatient provider. These findings are similar to those
reported in other studies 28-32, 40. These can be
explained. First, the availability of drugs in a facility was considered
the most important factor perhaps due to the fact that medicines often
account for the largest share of costs for accessing care. For instance,
a study among diabetes patients in Kenya showed that medicines alone
accounted for 52.4% of the average annual direct patient costs in Kenya41. Besides, 36.1% of the population in Kenya is poor
making the purchase of medicines an additional burden thus the
preference for facilities that they know they would get medicines19.
Distance from the household to a health facility was the second most
important factor influencing NHIF members’ choice of an outpatient
provider. Similar to medication, distance to facilities places both a
financial and physical burden on NHIF members as it influences both the
transport costs to a facility and the suffering as one moves from their
household to the facility. Transport costs were the second significant
contributor to direct patient diabetes costs among patients in Kenya41. In another study in Kenya, transport costs alone
increased the incidence of catastrophic health expenditure from 4.52%
to 6.58% with a larger share of this being in rural settings where
individuals from rural settings were over five times more likely to
experience catastrophic health expenditure from transport costs to
health facilities compared to their urban counterparts42. Even though the government targets to have the
whole population to be within a 1-hour travel time to a health facility,
spatial access estimates indicate that nearly 11% of the population
still leaves outside the 1-hour travel time to facilities43. Anecdotal evidence suggests that spatial access
estimates may be worse for NHIF-contracted outpatient facilities given
that NHIF has contracted less than half of the facilities in Kenya.
It is not surprising that waiting time at the facility until
consultation was the third most important factor that NHIF members
considered important. This finding is similar to what has been reported
in other studies 24, 29, 33. For instance, in South
Africa, Honda et al. found that waiting time was also an important
non-clinical quality of care factor that influenced attendance to public
health facilities 29.
LIMITATION
Findings from our study should be interpreted in light of the following
limitation. The findings from the study may not be generalizable to the
whole country given the approach and number of counties included.
Despite this, these findings provide nuances to the literature on people
or patients’ choice of health facilities and provide evidence to inform
further NHIF reforms for UHC in Kenya.
POLICY IMPLICATIONS
This limitation notwithstanding, the study offers several policy
implications. First, for communication between NHIF and NHIF members
especially in rural settings to be effective, there is a need to use
locally relevant platforms that members can easily interact with such as
local radio stations rather than via the website or social media
platforms that are not accessible. Second, NHIF should revise the
contractual process with keen consideration on revising provider payment
mechanisms and how facilities from historically marginalised areas are
inspected. Third, the NHIF should initiate the process of contracting
private providers, especially in areas where few public providers exist
and where alternative providers do not exist within the 1-hour travel
time from the population’s households. Fourth, the government and
private facilities should prioritise the availability of drugs in their
facilities to make sure that the population can access them rather than
have to buy elsewhere out-of-pocket. Related to this, the NHIF should
ensure that contracted facilities have drugs every quarter perhaps
through close supervision. Fifth, providers should also prioritise the
other important factors highlighted, particularly, reducing waiting
times at the facility, improving the attitudes of their staff, enhance
the cleanliness of the facility and the opening hours with a focus to
have the facility open day and night including weekends.
CONCLUSION
Our study highlighted an urban-biased level of awareness of the
NHIF-contracted outpatient facility selection process among NHIF members
in Kenya and the important factors that NHIF members consider when
choosing a facility. Therefore, there is a need to address barriers that
limit awareness reach among rural NHIF members whilst incorporating
factors preferred by NHIF members into contracting arrangements between
NHIF and healthcare providers as well as service provision improvement
at the facility level.