User perceptions of affordability of methadone maintenance treatment in Kenya: A mixed methods analysis

Methadone Maintenance Treatment (MMT) is a global evidence-based treatment intervention combining pharmacological and psychological approaches for the management of opioid use disorder. MMT in Sub-Saharan Africa currently faces significant sustainability challenges amid donor funding transitions. This study examined user perceptions of affordability for MMT services in Kenya using an adapted socio-ecological framework to inform sustainable financing models.

An explanatory mixed-methods design was employed with 44 MMT participants interviewed at an urban facility in Nairobi, Kenya. Contingent valuation methods assessed user perceptions of affordability through focus group discussions, while quantitative analysis examined socio-demographic correlates. Analysis compared participant affordability based on a threshold identified in the study (USD 3.9) and compared to government costs of treatment per patient per month (USD 32). Framework and thematic analyses were aligned with socio-ecological levels to explore nuances in perceived affordability.

Median perceived affordability was USD 0.8 monthly for clinic-based services and USD 2.3 for community-based services. Participant affordability sharply declined at a critical threshold of USD 3.9 with only 2% demonstrating perceived ability to absorb the equivalent of government cost recovery amounts. Transportation burden emerged as the strongest predictor of affordability (p≤0.001), with associations with individual income and prior opioid use disorder showing statistical significance (p≤0.05). Female participants were three times more willing to absorb treatment costs compared to males. Economic constraints, intersectional stigma, and employment discrimination created systematic barriers to participant affordability.

The substantial gap between patient perceptions of affordability and service provision costs provides evidence that patient fees alone cannot sustain MMT programs. Transport burden represents the most significant modifiable barrier, while community-based delivery models show promise for enhancing sustainability. Findings support maintaining free or highly subsidized services combined with decentralized delivery approaches for sustainable MMT financing in resource-limited settings.