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.