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The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018
  1. Paola Salari1,2,
  2. Laura Di Giorgio3,
  3. Stefania Ilinca4,5,
  4. Jane Chuma6
  1. 1Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
  2. 2Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
  3. 3The World Bank, Washington, District of Columbia, USA
  4. 4Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
  5. 5European Centre for Social Welfare Policy and Research, Vienna, Austria
  6. 6The World Bank, Kenya Country Office, Nairobi, Kenya
  1. Correspondence to Dr Paola Salari; paola.salari{at}


Introduction Progress towards effective service coverage and financial protection—the two dimensions of Universal Health Coverage (UHC)—has been limited in Kenya in the last decade. The government of Kenya has embarked on a highly ambitious reform programme currently being piloted in four Kenyan counties and aiming at national rollout by 2022. This study provides an updated assessment of the performance of the Kenyan health system in terms of financial protection allowing to monitor trends over time. In light of the UHC initiative, the study provides a baseline to assess the impact of the UHC pilot programme and inform scale-up plans. It also investigates household characteristics associated with catastrophic payments.

Methods Using data from the Kenya Household Health Expenditure and Utilization Survey (KHHEUS) 2018, we investigated the incidence and intensity of catastrophic and impoverishing health expenditure. We used a logistic regression analysis to assess households’ characteristics associated with the probability of incurring catastrophic health expenditures.

Results The results show that the incidence of catastrophic payments is more severe for the poorest households and in the rural areas and mainly due to outpatient services. Results for the impoverishing effect suggest that after accounting for out-of-pocket(OOP) payments, the proportion of poor people increases by 2.2 percentage points in both rural and urban areas. Thus, between 1 and 1.1 million individuals are pushed into poverty due to OOP payments. Among the characteristics associated with the probability of incurring OOP expenditures, socioeconomic conditions, the presence of elderly and of people affected by chronic conditions showed significant results.

Conclusion Kenya is still lagging behind in terms of protecting its citizens against financial risks associated with ill health and healthcare seeking behaviour. More effort is needed to protect the most vulnerable population groups from the high costs of illness.

  • health systems
  • public health
  • KAP survey

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  • Handling editor Valery Ridde

  • Contributors All authors are responsible for the conceptualisation and design of the study. PS carried out the data analysis and wrote all manuscript drafts. LDG and SI provided critical reviews of the data analysis and all manuscript drafts. JC provided overall guidance to the study and critical reviews of the data analysis and all manuscript drafts. All authors read and approved the final manuscript.

  • Funding This study was supported by the World Bank. The World Bank (through the Kenya Health Sector Support Project) and the WHO provided funding for the 2018 Kenya Household Health Expenditure and Utilisation Survey.

  • Disclaimer The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organisations, or those of the Executive Directors if the World Bank or the governments they represent.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available.

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