CORE PACKAGE FINAL REPORT:
Improving Access to Family Planning Services in Public Sector Facilities for Poor/Underserved Populations in Kenya
POLICY Project
November 2005
Improving Access to Family Planning Services in Public Sector Facilities for Poor/Underserved Populations in Kenya
POLICY Project
November 2005
The POLICY Project is funded by the U.S. Agency for International Development (USAID) under Contract No. HRN-C-00-00-00006-00. POLICY is implemented by Futures Group in collaboration with the Centre for Development and Population Activities (CEDPA) and Research Triangle Institute (RTI). The views expressed in this report do not necessarily reflect those of USAID or the United States government.
Contents
Abstract iii
Abbreviations iv
I. Introduction 1
II. Context and Policy Environment 3
III. POLICY Core Package Activities and Results 7
IV. Key Research Findings and Stakeholder Recommendations 10
V. Conclusion 19
Abstract
The POLICY Project implemented a core package of research and technical assistance to assist the government of Kenya in understanding the costs associated with the provision of family planning (FP) services over the period from 2003–2005. In implementing the financing part of the package, special attention was paid to addressing the needs of the poor, with free or highly subsidized services being delivered to such groups. This subsidy aspect of the package was introduced at the stage of developing guidelines for the implementation of user fees, waivers, and exemptions. Implementation of user fees was designed to generate revenue to maintain availability of FP services and strengthen the quality of those services while expanding access to the poor and underserved. Activities included analysis of current fee charging practices; analysis of operational policies affecting FP fees, waivers, and exemptions; market segmentation analysis; review of willingness and ability to pay; and development of draft pricing guidelines for FP services. POLICY core package activities led to a critical change of position on the merits of cost sharing by the Ministry of Health. The draft pricing guidelines will enable the government to enact an effective, evidence-based approach to implementing user fees, waivers, and exemptions for FP services. These results will ultimately lead to improved access to high-quality FP services for all social groups, including the the poor and currently underserved populations.
This report documents the POLICY Project’s core package in Kenya, taking into consideration the family planning and economic context in which the FP services are provided; key stakeholders; activities and products; key research findings; and lessons learned. The FP financing experience in Kenya has potential for replication in other countries.
Abbreviations
AIDS acquired immune deficiency syndrome
DFID Department for International Development (United Kingdom)
DHMB District Health Management Boards
DHMT District Health Management Team
DRH Division of Reproductive Health
FP family planning
GOK government of Kenya
HIV human immunodeficiency virus
IUD Intrauterine contraceptive device
DHS Demographic and Health Survey
KFW Kreditanstalt für Wiederaufbau
Ksh Kenya shilling
MCH maternal and child health
MOH Ministry of Health
NCPD National Coordinating Agency for Population and Development
NGO nongovernmental organization
NHSSP National Health Sector Strategic Plan
PGH provincial general hospital
PHMT Provincial Health Management Team
PMO Provincial Medical Officer
RH reproductive health
SES socioeconomic status
STI sexually transmitted infection
TFR total fertility rate
UNFPA United Nations Population Fund
USAID United States Agency for International Development
WHO World Health Organization
iii
Kenya Core Package Final Report
I. Introduction
Despite a historically strong performance, Kenya’s family planning (FP) program is showing signs of stagnation, as evidenced by a slowing or reversal of progress in its fertility and contraceptive use indicators in the 2003 Demographic and Health Survey (DHS).
In response to declining public funding for FP services and to stimulate demand for FP services by improving quality, the government of Kenya (GOK) has indicated a commitment to introducing cost sharing for public health services, including family planning. At the same time, the government remains strongly committed to expanding access to health services among those who cannot afford to pay. Therefore, the introduction of user fees for FP services has been controversial. In addition, there has been a lack of consistency in the application of user fees, waivers, and exemptions in current practice. Facilities must charge fees to maintain the availability of services, but a lack of data on costs, the absence of clear guidelines on pricing, and ineffective implementation of existing policies have led to substantial variations in fees and the application of waivers and exemptions across different facilities. As a result, it is likely that the poor and other underserved populations are being denied access to FP/RH services because they are unable to pay. Facilities are not generating enough revenue to ensure the quality and sustainability of services, and user fees are not used appropriately and effectively to improve service quality.
In response to this situation, the POLICY Project implemented a core package of research and technical assistance to assist the government in understanding the costs associated with the provision of FP services, appropriately targeting resources to the neediest groups for free or reduced-price services,[1] and developing guidelines for the implementation of a user fee and waiver/exemption structure that will generate sufficient revenue to maintain availability of FP services and strengthen the quality of those services while expanding access to the poor and underserved.
POLICY core package activities led to a critical change of position on the merits of cost sharing by the Ministry of Health (MOH). POLICY helped to draft pricing guidelines that will enable the government to enact an effective, evidence-based approach to implementing user fees, waivers, and exemptions for FP services. These results will ultimately lead to improved access to high-quality FP services for the poor and underserved populations of Kenya.
This report documents the POLICY Project’s core package activities and key findings in Kenya. The following section introduces the FP and economic context in Kenya, stakeholders, and analytic frameworks. Section III describes the activities undertaken and results achieved by the POLICY Project, including research and analysis, gaining stakeholder consensus on findings, and development of pricing guidelines. Section IV reports key findings from the user fee and market segmentation analyses and conclusions from the dissemination workshops. The final section discusses lessons learned and the potential impact of the research findings and guidelines developed under this core package.
II. Context and Policy Environment
Family Planning and Economic Context
Historically, Kenya’s FP program has been one of the strongest in sub-Saharan Africa. Kenya has experienced substantial fertility decline during the past 30 years. In the late 1970s the total fertility rate (TFR) exceeded 8.0. The 1998 Kenya DHS reported a decline to 4.7. The contraceptive prevalence rate for currently married women was 39 percent, and for modern methods it was 32 percent. However, unmet need for family planning remained high, with 14 percent of married women having an unmet need for spacing purposes and 10 percent for limiting.[2] Despite this unmet need, the use of modern contraceptives in the country increased significantly, resulting in a notable decline in fertility rates and marked improvement in the quality of life and health of women and children.
The 2003 DHS depicted a worsening FP/RH situation. The TFR remains high at 4.9. There remains a substantial unmet need for family planning services: 25 percent of married women of reproductive age had an unmet need (spacing and limiting) for family planning. The reproductive-age population, especially those aged 15–29 years, is growing fast. The female population aged 15–29 is expected to increase by 50 percent between 2000 and 2020. The contraceptive method mix has become more concentrated on spacing methods, especially on the relatively expensive injectable. The proportion of men and women using longer-term, more cost-effective methods (IUD, male/female sterilization) has declined significantly, even though an increasing proportion of users want to prevent rather than space future births. The number of contraceptives delivered to service delivery points declined between 2000 and 2001 and, as a result, both the growth in contraceptive use and decline in fertility have plateaued. [3] There is evidence of growing numbers of unsafe abortions, especially among young women.
Effective government policies and strategies to guide decisionmaking are lacking in many key areas, including generating and allocating financial resources, improving quality of services, and matching the contraceptive method mix to women’s and couples’ needs and desires.
Economic indicators remain poor. The 2004 poverty rate was 60 percent, and the 2002 Gross National Income per capita was US$360. Per capita government budget allocations to health are less than US$5. In 2001, GOK health spending was 6.2 percent of total government budget, well below the 15 percent target set by the Abuja Declaration. The entire health sector is grossly under-financed, and there is no single budget line for FP services and commodities. Per capita government allocations to the health sector have declined by more than half during the past 20 years, and by more than two-thirds in real terms (now about $3 per capita). There is also evidence that the attention of political leadership, the government, and development partners has increasingly shifted to the country’s HIV/AIDS program at the expense of family planning. There is now more support for the HIV/AIDS program in terms of attention, resource allocation and high-level commitment, with family planning increasingly receiving less attention and financial support.
Kenya is heavily dependent on donors for the provision of FP services and commodities. Donors fund 100 percent of the costs of all contraceptive commodities except condoms,[4] including all contraceptives provided by nongovernmental organizations (NGOs).[5] There is growing donor fatigue over escalating commodity costs. As part of the response to declining public sector resources, over the past decade the GOK has been implementing a “cost-sharing” program in the health sector, under which fees are charged to service recipients to cover part of the costs. In its new National Condom Policy and Strategy,[6] for instance, the government has made the long-term commitment to gradually introduce fees for all public sector health services, including family planning, in an effort to shore up the health system and expand access. At the same time, the government is committed to the effective application of a system of waivers and exemptions[7] from fees for poor clients and other designated groups (e.g., youth, persons living with HIV/AIDS).
According to the MOH fee guidelines (last reviewed in 1994), MCH/FP and antenatal and postnatal services are to be provided free. In practice, however, public health facilities have put in place an “access fee” under the direction of the District Health Management Boards (DHMBs). Typically, these are as follows: Ksh. 20–100 at the registration desk to gain access to all services; a “commodity fee” of about Ksh. 50 per visit, usually dependent on the client’s method choice; and a “supplies fee,” dependent on the availability of items such as paraffin, gloves, cotton wool, needles, and syringes.
Whereas previous studies suggest there is substantial willingness and ability to pay such fees, several issues remain unclear, such as the actual charges at the operational level by facility type, socioeconomic status, and gender of clients; the basis for setting the fee; and mechanisms in place and utilized to provide effective access to FP services by the poor (e.g., waivers and exemptions). Available evidence suggests that funds from FP services typically subsidize other departments or are used for non-service related purposes (e.g., staff welfare activities such as transportation to funerals) rather than being used to improve the quality of FP services (as required by the Exchequer and Audit Act) and thereby the utilization of services.
In spite of the MOH cost-sharing guidelines that outline the existence of waivers and exemptions for the provision of health services, including MCH/FP, in public hospitals, the system remains ineffective in its implementation. It continues to be characterized by leakage of benefits to undeserving cases, manipulation, and a lack of clear eligibility criteria. In addition, public health facilities have limited their provision of waivers and exemptions, citing declining resources from the central government as a reason. The situation is worse with respect to FP/RH, where the MOH has remained silent on fee policy.
It is highly likely that with increasing poverty levels, the poor and other underserved populations are being denied access to FP services on the basis of inability to pay. Against the background of government’s commitment to address poverty issues in its blueprint for development, “Economic Recovery Strategy for Wealth and Employment Creation,” the strengthening of the system of waivers and exemptions is critical. There is an urgent need to re-examine the levels of fees charged for FP services and to put in place operational policies that provide a safety net to mitigate against the adverse effects of cost sharing.
Stakeholders
Various stakeholders play a key role in the financing of FP services and commodities in the public health sector and in enhancing access to FP services among the poor and underserved:
· Government institutions entrusted with FP issues include the Ministry of Health (MOH) Division of Reproductive Health (DRH), and the Ministry of Planning National Coordinating Agency for Population and Development (NCPD). The MOH is entrusted with the responsibilities of coordination, policy development and implementation, quality control, resource mobilization, monitoring and supervision, and development and issuance of pricing guidelines.
· Development partners and related technical agencies (WHO, USAID, UNFPA, DFID, KFW) provide technical assistance in such areas as the development of guidelines and policies, systems strengthening, capacity building, and resource mobilization.
· Provincial level stakeholders, such as the Provincial Health Management Team (PHMT) and Provincial Medical Officers (PMO), are responsible for monitoring and supervision.
· District level stakeholders (District Health Stakeholders Forum, DHMB, District Health Management Team (DHMT), District Treasury) develop and implement district FP/RH workplans, review reports on the implementation of FP/RH programs at the district level, arrange for annual auditing of the FP/RH funds, and carry out needs assessments for family planning and capacity building.