Ensuring access to health care with the introduction of user fees: a Kenyan example

Many developing countries are considering or in the process of implementing user fees for government health care services. These fees have the benefit of generating much needed revenue and discouraging unnecessary utilization, but have the potential negative effect of excluding low income individuals from necessary medical care. In 1989, the Ministry of Health of the Government of Kenya briefly implemented user fees for government facilities which included a system for waiving fees for low income patients. This paper examines how that system might have worked in theory and how it worked in practice. Survey data from three districts in Kenya are used to estimate the percentage of health center outpatient fees that may need to be waived to avoid undue burden on low income households. The percentage of outpatient fee exemptions range from 11 to 34% depending on the district and the criterion used to determine ability to pay. This paper then assesses the extent to which ability to pay can be determined by readily obtainable information on patients' socio-economic characteristics. It is shown that these characteristics do predict ability to pay, but not with the degree of accuracy necessary to use as the sole criteria for granting exemptions. Thus, although the evidence from Kenya indicates that the level of outpatient fees could be paid by the majority of the population without undue burden, a minority would require fee exemptions. The main obstacle to implementing a system of exemptions is the inability to easily identify those unable to pay.