Who pays and how much? A cross-sectional study of out-of-pocket payment for modern contraception in Kenya

Abstract

ObjectivesOut-of-pocket (OOP) payment for modern contraception is an understudied component of healthcare financing in countries like Kenya, where wealth gradients in met need have prompted efforts to expand access to free contraception. This study aims to examine whether, among public sector providers, the poor are more likely to receive free contraception and to compare how OOP payment for injectables and implants—two popular methods—differs by public/private provider type and user’s sociodemographic characteristics.Design, setting and participantsSecondary analyses of nationally representative, cross-sectional household data from the 2014 Kenya Demographic and Health Survey. Respondents were women of reproductive age (15–49 years). The sample comprised 5717 current modern contraception users, including 2691 injectable and 1073 implant users with non-missing expenditure values.Main outcomeRespondent’s self-reported source and payment to obtain their current modern contraceptive method.MethodsWe used multivariable logistic regression to examine predictors of free public sector contraception and compared average expenditure for injectable and implant. Quintile ratios examined progressivity of non-zero expenditure by wealth.ResultsHalf of public sector users reported free contraception; this varied considerably by method and region. Users of implants, condoms, pills and intrauterine devices were all more likely to report receiving their method for free (p<0.001) compared with injectable users. The poorest were as likely to pay for contraception as the wealthiest users at public providers (OR: 1.10, 95% CI: 0.64 to 1.91). Across all providers, among users with non-zero expenditure, injectable and implant users reported a mean OOP payment of Kenyan shillings (KES) 80 (US$0.91), 95% CI: KES 78 to 82 and KES 378 (US$4.31), 95% CI: KES 327 to 429, respectively. In the public sector, expenditure was pro-poor for injectable users yet weakly pro-rich for implant users.ConclusionsMore attention is needed to targeting subsidies to the poorest and ensuring government facilities are equipped to cope with lost user fee revenue.

Who Experience Out-of-Pocket Expenditures for Modern Contraceptive Use in Indonesian Universal Health Coverage System?

“…It is interesting to note that OOP on FP services resulting from this study is significantly associated with health insurance ownership (public-subsidized compared to public non-subsidized and private insurances) and contraception types (LARC compared to short-acting methods). This finding has a similarity and contrast with the prior research about OOP determinants in several countries 18,19,[21][22][23] . In the Indonesian UHC system, socioeconomic characteristics were determined by health insurance ownerships, wherein public-subsidized refers to lower-income groups, and non-subsidized and private insurance refer to wealthier segments.…”

“…There was a lack of comprehensive data to estimate OOP expenditure on reproductive health, including FP services. While FP services were intended to be free within the public health system, a study by 18 indicated that only one-half of modern method users reported obtaining their free methods. A study in Burkina Faso also mentioned that reproductive health, including FPthrough the public health center, is paid 19 .…”

Exploring factors constraining utilization of contraceptive services among adolescents in Southeast Nigeria: an application of the socio-ecological model

“…Finally, poverty was reported to be a barrier to access to contraceptives for adolescents. This is a commonly reported determinant of access to health services, particularly in contexts where out-of-pocket payment is prevalent [44,45]. Although contraceptives are provided free of charge in public health facilities in Nigeria, our study has highlighted several supply-side factors that discourage adolescents from seeking health services from public health facilities.…”

Free Access to a Broad Contraceptive Method Mix and Women's Contraceptive Choice: Evidence from Sub‐Saharan Africa

“…For example, injectables, a short-term method, are the most popular contraceptive in SSA (Department of Economic and Social Affairs at United Nations 2019). In Kenya, all public sector users were supposed to receive contraceptives for free, but users of injectables were more likely to pay compared to users of implants, IUDs, pills, or condoms, indicating women's strong preference for injectables (Radovich et al 2019). If free access to LARC and SARC reflected more resources to cover LARC and some previously not-covered SARC methods, such as injectables, LARC users might switch to injectables when LARC were provided free of charge as defined by the treatment variable.…”