Equity is a desired outcome of a country’s health system. Inequity exists when there are differences in health outcomes or healthcare use that are avoidable. How does Kenya fare with regard to health equity? Not too well, according to the latest Kenya Demographic and Health Survey ( 2014 ). For example, children born in the poorest households are 20 per cent more likely to die before their fifth birthday compared to those born in the richest households. Children stunted due to poor nutrition make up 36 per cent in the poorest quintile and 14 per cent in the richest.
This is in large measure due to inequities in the use of essential health services. For example, 93 per cent of women from the richest households deliver in health facilities, compared to 30 per cent of poor women.
While 82 per cent of women living in urban areas deliver in health facilities, only 50 per cent in rural areas do so. The variation between the counties is even more dramatic. Well over 90 per cent of deliveries in Kiambu county are overseen by skilled medical personnel, compared to only 22 per cent in Wajir. This illustrates how inequities operate not just along socioeconomic but also geographical lines.
One explanation for these disparities is inequity in the way the health system is financed. Equity in health financing means that citizens should pay for healthcare based on their ability to pay; simply put, the rich should pay more than the poor.
While government financing follows this principle, only 7.5 per cent of government spending is for health, according to the Ministry of Health’s 2014-15 National and County Budget Analysis report. Moreover, out-of-pocket expenditure that is regressive in nature (the poor pay more than the rich as a share of their income) accounts for 27 per cent of total health spending, according to National Health Accounts estimates.
Out-of-pocket payments discourage many from seeking services and can result in financial hardship for households. According to recent analyses in the Kenya Household Expenditure and Utilisation Survey ( 2013 ), nearly 500,000 Kenyans are made poor annually because of the out-of-pocket healthcare payments.
As expected, the poor suffer more from the burden of paying for healthcare compared to the rich. Having health insurance would remedy the situation, but health insurance coverage in Kenya is low and inequitable. Only 17 per cent of Kenyans own health insurance, ranging from three per cent in the poorest quintile to 43 per cent in the richest quintile.
Another reason for inequities in healthcare access is the pattern of geographical allocation of healthcare resources. According to the county fact sheets published by the USAID-funded Health Policy Project, Kirinyaga, with a population of approximately 600,000, has 243 healthcare facilities and 27 doctors and clinical officers in the public sector, while Mandera, with a population of more than one million, has only 84 healthcare facilities and nine clinical officers and doctors in the public sector.
Also, public resources are disproportionately allocated to hospitals compared to health centres and dispensaries. Hospitals are often located in urban areas and typically serve wealthier clients as a result of charging user fees, while services in health centres and dispensaries are free.
How can we remedy this? First, the national government should increase the budgetary allocation to health. Second, it should use part of these resources to subsidise NHIF health insurance for Kenyans not currently covered by the insurer. In a country where close to half of the population lives below the poverty line, requiring informal sector households that constitute close to 80 per cent of the population to pay a flat monthly premium for NHIF cover (currently Sh500 ) is both inequitable and hard to enforce.
The government should instead collect revenue through more equitable channels such as income tax and indirect consumption taxes, and use that to pay for health insurance. The county governments, especially those in poor and marginalised regions, should prioritise building healthcare infrastructure and attracting health workers through monetary and non-monetary (eg opportunities for training and clear career progression paths) incentives.
They should also prioritise primary healthcare. Such health financing reforms would push Kenya closer to the ideal of Universal Health Coverage, whose goal is to ensure that all Kenyans can access high quality health services without unnecessary financial hardship.
Dr Edwine Barasa is a health economist at the KEMRI-Wellcome Trust Research Programme in Nairobi. Dr. Ravishankar is a health financing specialist and Kenya Lead for the African Health Markets for Equity project.