Examining informal payments for healthcare in Kenya and the implications on equitable access.

Background: Informal payments for healthcare are payments made by patients to health providers outside the officially determined payment channels. Such payments worsen inequities in access to care and financial protection. Globally, there is insufficient evidence on the burden of informal payments on households and the effectiveness of measures to curb them. This PhD study examined the prevalence, determinants, value, context-specific drivers (including gender), existing and potential strategies to tackle informal payments.

Methods: I conducted the study in 8 public health facilities and households in the health and demographic surveillance sites in two purposively selected counties (urban and rural), in Kenya. I employed a sequential exploratory mixed-methods design. In the first phase, I conducted 35 semi-structured interviews with health facility staff and county/sub-county managers and 8 focus group discussions with patients (n=79) and analyzed the data thematically. In the second phase, I administered a household survey among 1086 households and conducted descriptive and regression analysis.

Results: In the two study counties, 6.8% (95% CI: 5.3%,8.7%) of households had paid informal payments in the 12 months preceding the survey. Urban residents, patients with chronic diseases, and single people were more likely to pay informal payments (p < 0.05). The median value of informal payments was $3.84 (IQR $1.92- $7.67). Informal payments were more common at public (80%), secondary and tertiary level facilities (75%), and outpatient services (69%). Key supply-side drivers were scarcity (e.g., shortages of medical supplies and health workers, and low staff salaries) and inadequate oversight over health facilities and workers. Charging and payment of informal payments were perceived to be more common among men, while female patients were more likely to report informal payment incidents. Existing strategies to tackle informal payments were perceived to be ineffective.

Conclusions: The existence of multiple drivers of informal payments requires multifaceted approaches to tackle them. Addressing deficiencies in health system financing, governance, and social networks, as root causes of informal payments, should be prioritized.