Achieving EQUITY for the Poor in Kenya: - Health Policy Initiative

PRELIMINARY FINDINGSJUNE 2009 DRAFTDISCUSSIONBRIEFAchieving EQUITY for the Poor in Kenya:Understanding the Level of Inequalities and Barriers to Family Planning ServicesWhile trends vary by country, one point is clear:Countries that have achieved high levels of familyplanning and reproductive health (FP/RH) service usehave done so by reducing inequalities in serviceaccess. 1 Given the sometimes large gaps in serviceuse between the poorest and wealthiest populations,strategies to reach the poor can help countries expandoverall FP/RH service access—ultimately leading toslower population growth, less burden on strainedsocial services and natural resources, and improvedmaternal and child health (see Box 1). Reducinginequalities in service use could have far-reachingimplications beyond improved reproductive health byhelping families to create a path out of poverty andenhance quality of life.To design effective FP/RH policies and strategies forreaching the poor in Kenya, it is essential tounderstand their needs and challenges. In response,the USAID | Health Policy Initiative, Task Order 1,carried out various analyses (including marketsegmentation, focus groups, and policy and financingreviews) to quantify the level of inequality in FP/RHservice access, identify the barriers the poor face inseeking services, and explore where services areneeded most. The complete findings will bepublished in a forthcoming report. This brief presentsthe preliminary findings to inform policy dialogueand discussion.What is the Current Level ofContraceptive Use in Kenya?Kenya’s strong national FP program contributed to asignificant increase in the contraceptive prevalencerate (CPR) from 7 percent (modern and traditionalmethods) in the 1970s to 39 percent by 1998. Theincreasing CPR helped contribute to a decline in thecountry’s total fertility rate (TFR), from an average1BOX 1 | Kenya Benefits from Increased FP AccessAn analysis of the contribution of family planning to theMillennium Development Goals (MDGs) shows thatsatisfying unmet FP need in Kenya would avert 14,040maternal deaths and 434,306 child deaths by the MDGtarget date of 2015. Moreover, FP use helps to reduce thesize of the population in need of services. Thus, as shown inFigure 1, the cost savings in providing services to meet fiveof the MDGs outweigh the additional costs of familyplanning by a factor of almost 4 to 1.Figure 1. Social Sector Cost Savings and FamilyPlanning Costs in Kenya, 2005–2015Source: Health Policy Initiative, Task Order 1. 2006. “Achieving theMDGs: The Contribution of Family Planning—Kenya.” Washington, DC:Futures Group International.of 8.1 children per woman in the late 1970s to 4.7 by1998. However, both CPR (39%) and TFR (4.8)remained nearly constant from 1998–2003. 2The percentage of women using modern FP methodsalso has not increased over the last five years forwhich published data are available. According to theKenya Demographic and Health Survey (KDHS), in1993, 27 percent of married women age 15–49 were

PRELIMINARY FINDINGSJUNE 2009 DRAFTusing a modern method (e.g., oral pills, condoms,intrauterine devices [IUDs], injectables, implants,sterilization). CPR for modern methods increased toabout 32 percent in 1998 and remained at this levelthrough 2003. The percentage of women not usingany method decreased from 67 percent in 1993 to 61percent in 1998, leveling off at just under 61 percentin 2003 (see Figure 2).The recent stagnation in contraceptive use and totalfertility fuels continued rapid population growth,making it difficult for Kenya to achieve its nationalsocioeconomic development goals.What Is the Level of Inequalityin FP/RH Service Use?Defining who “the poor” are is a challenge. Simplylooking at indicators such as the national poverty lineis inadequate when trying to determine how to ensurethat resources get to those most in need because, inmany developing countries, a large proportion of thepopulation lives below the poverty line. Recognizingthis, a quintile analysis is typically used. Oneapproach, popularized by the World Bank and MacroInternational, involves dividing the population intofive equal groups based on an assessment ofsocioeconomic status (SES) according to a standardof living index. This approach recognizes that factorsother than income, such as assets and householdamenities, contribute to the SES of families. Analysesusing this method and data from the KDHS arepresented below.Poor Women Lack Access to Family Planning.Women from the lowest SES groups are the leastlikely to use modern contraceptive methods, and,from 1993–2003, Kenya made no progress in closingthe gap in FP use between the low and high SESgroups (see Figure 3). In 2003, only 12 percent ofwomen from the very low SES group used a modernFP method while 45 percent of women from the veryhigh SES group did the same. Socioeconomic statusaffects access to and use of services, as there is an 8–14 percentage point increase in modern contraceptiveprevalence use for each increase in quintile status.Unmet Need for Family Planning is Highest amongthe Poor. Unmet need refers to the proportion ofmarried women of reproductive age who want toFigure 2. Contraceptive Prevalence by Type ofMethod in Kenya, 1993–2003 (KDHS)% of married women age 15-4980604020067.327.35.561.0 60.731.5 31.57.5 7.81993 1998 2003Not using Modern Method Traditional MethodFigure 3. Modern CPR by Socioeconomic Statusin Kenya, 1993–2003 (KDHS)% of married women 15-4960%50%40%30%20%10%0%1993 1998 2003Very Low Low Middle High Very HighFigure 4. Unmet FP Need by SocioeconomicStatus in Kenya, 2003 (KDHS)% of married women 15-4935%30%25%20%15%10%5%0%Unmet need forspacingUnmet need forlimitingTotal unmet needVery Low Low Middle High Very High2

PRELIMINARY FINDINGSJUNE 2009 DRAFTwait two or more years to have a child, but are notusing contraception. Reaching women with unmetneed is often viewed as the “low hanging fruit” interms of expanding FP access and increasing CPR,because this is a group that has already expressed adesire to space or limit future pregnancies and maybe more receptive to FP use than other non-users.In Kenya, women in the very low, low, and middleSES groups have the highest level of unmet need forfamily planning (see Figure 4). In fact, total unmetFP need among women in the very low (33%) andlow (30%) SES groups is nearly double the unmetneed found among the very high (17%) and high(17%) SES groups.Many of the FP Clients Served by the Public Sectorare Not Poor. Typically, public sector services areintended to reach the groups who are most in needand are unable to afford services elsewhere. InKenya, the public health sector provides the majorityof FP planning services (53%). Other providersinclude the commercial sector (e.g., private hospitals,pharmacies/chemists, and shops) (35%) and NGOs,religiously-affiliated clinics, mobile clinics, andcommunity-based distributors (11%). A look at thesocioeconomic status of FP clients of the differentproviders shows that the very low and low SESgroups represent a small proportion of the clientele inall sectors (see Figures 5a–c). Most alarming,however, is the fact that these groups account foronly about one-fourth (26%) of the clients served byKenya’s public sector, which, ideally, should cater tothe needs of the poor. In practice, about half of thepublic sector’s clients are from the high (27%) orvery high (24%) SES groups.Socioeconomic Status Affects Reproductive andMaternal Health. Inequalities between the poorestand wealthiest groups are also evident in otherreproductive and maternal health indicators (seeTable 1). Among women in the very low SES group,nearly half will marry by age 18 (45%) and twothirds(66%) will give birth before they reach 20years of age. In contrast, about 8 in 10 women in thevery high SES group have a delayed marriage (age 18or older) and 7 in 10 have a delayed first birth (age20 or older). Women in the lowest SES group arealso least likely to seek antenatal care (42%), haveinstitutional deliveries (17%), or enjoy healthy birthspacing (35%). These factors affect the health ofwomen and their children.Figure 5. Socioeconomic Status of FP Clienteleby Sector in Kenya, 2003 (KDHS)(a) Public Sector27 2423(b) NGO Sector3416(c) Commercial Sector20521317321011974Very lowLowMiddleHighVery highVery lowLowMiddleHighVery highVery lowLowMiddleHighVery highTable 1. Reproductive/Maternal Health Indicatorsby Socioeconomic Status in Kenya, 2003 (KDHS)Antenatal careInstitutionaldeliveryDelayedmarriage (atage 18 or older)Delayedchildbearing(first birth atage 20 or older)Birth spacing(36 months orlonger)VeryLow Low Middle High4217553335463372434353396844455955805948VeryHigh70778369543

PRELIMINARY FINDINGSJUNE 2009 DRAFTPeople say that users can deliver babies withtwo heads, and some report continuousheadaches and backaches which make a womanunable to work, such as plowing the land… Thisis the reason why I have not used, because Ihave to do a lot of hard work to feed mychildren. (Female discussant, rural poor,Nyanza)Male InvolvementWomen seeking maternal and child health services ata hospital in Kisumu. Photo by Eric Ajwang.What Keeps the Poor fromAccessing FP Services?The data above make clear that the poor are lesslikely to use FP services and also have the highestunmet need for family planning when compared toother groups. Further, they are less likely to benefitfrom the health services intended to meet their needs.To better understand the barriers faced by the poor,the Health Policy Initiative conducted 33 focus groupdiscussions with members of urban and rural poorpopulations in Nyanza and Coast Provinces in Kenya.Participants included women under age 30, both FPusers and non-users; women over age 30, both usersand non-users; and men. The project also interviewed23 FP providers and conducted short exit interviewswith 380 clients at selected sites. Barriers emergingfrom the preliminary analysis are summarized below.Misinformation and MisconceptionsMany of the focus group discussants knew at leastone method of family planning, and many recognizedthe benefits of family planning, especially for thehealth of women and children. Notwithstanding,many participants only knew about certain methodsand were unaware of other methods, such as femalecondoms and implants. Despite a high awareness ofsome FP methods, discussants held misconceptionsabout the use of family planning. These myths andmisconceptions typically related to potential sideeffects, such as pain, infertility, or birth defects. Insome cases, such beliefs were based on personalexperiences, but most often were based on reportsfrom relatives or community members.4In general, there is limited communication aboutfamily planning between spouses. In urban areas,women who use contraceptives said they do sobecause they were motivated by friends or nurses, notby their husbands. Moreover, spousal opposition wasone of the key barriers mentioned in all thediscussions. According to female and malediscussants, men oppose FP use because they thinkwomen will become promiscuous, men want to havesons, or they believe having more children willultimately add to the wealth of the family. Womenwho use family planning might also be seen aschallenging men’s authority.The men do not like the idea of family planningbecause they think that when we go to the clinic,we go to hide so that we may be promiscuous.(Female discussant, urban poor, Nyanza)When a woman unilaterally decides to usecontraceptives without informing me, it meansshe is undermining my authority. (Malediscussant, urban poor, Nyanza)Sociocultural and Religious BarriersThe preferences for large families and for sons aredeeply held beliefs among members of thecommunity, not only among men. For some men,there is a competition within the community to havelarger families as this is believed to be a sign ofstrength and virility of the man and also of thefamily’s wealth, as well as a guarantee that the familylineage will continue. Women report that mothers-inlaw support the belief that wives are meant to bearchildren for their sons. Women also said that havingmany children, especially sons, is a way to ensuretheir position or authority within the family and tokeep their husbands from taking on additional wives.

PRELIMINARY FINDINGSJUNE 2009 DRAFTWhen you have children, a man can no longerthreaten you. (Female discussant, rural poor,Nyanza)Many discussants mentioned religion as a barrier, afact supported by the 2003 KDHS, in which 28percent of the poorest women said that religiousopposition is the main reason for non-use of familyplanning. Both Christian and Muslim discussants saidthat their religions prohibit FP use.It is prohibited in Islam, so I cannot support it.(Male discussant, urban poor, Nyanza)God forbids the use of contraception. It is likekilling or a form of abortion. (Older femalediscussant, rural poor, Nyanza)In some cases, discussants said that religious leadersare coming out in support of family planning andused references to religious teachings to support thisview. For example, religious beliefs recognize thatfood is from God, but that it has limits. Thus,Christians are encouraged to use wisdom in theirreproduction. Similarly, in Islam, it is desirous tohave only the number of children that one is able tocare for.Costs and Frequent StockoutsCosts for services include travel costs, lost wages orlost time for non-wage earners, costs for child care,and fees for services. The distances to health facilitiesare particularly prohibitive to residents of rural areas.Because to go to the health post is so far, wedon’t have money to go. Women also do nothave time to go. (Female discussant, ruralpoor, Coast)Costs are particularly burdensome for poor womenbecause of frequent stockouts of commodities.Women reported frustration at having to pay travelcosts, lose wages, plead with neighbors to watch theirchildren, and/or take time away from their dailychores, only to reach the facility and learn that the FPcommodities or other needed supplies are notavailable.their confidentiality and avoid being seen bymembers of their own community.Respondents also reported having to pay fees forservices. According to Kenyan government policy,FP services in government facilities are to beprovided for free, as are government-supplied FPcommodities distributed by private and NGOproviders. However, clients might have to payregistration costs, fees for medical tests, and, in somecases, fees for commodities and other hidden fees,which are not uniform across providers or evenwithin the same facility. Most public health facilitiesreported that oral pills are free, but that Norplant(e.g., Kshs500), IUDs (e.g., Kshs200), andinjectables (e.g., Kshs50) incur costs.Provider BehaviorSome discussants reported poor provider-clientinteractions, including limited counseling onavailable FP options and side effects as well ascondescending or unfriendly language. Providers alsoreported being overwhelmed by staff shortages andheavy workloads. In such cases, a provider noted, itis easier to provide the method the client asks than toinitiate a full counseling session. Even so, discussantsin urban areas mentioned generally having goodprovider-client interactions.Where is the Need Greatest?The need to focus FP resources to reach the poor isclear. However, “the poor” are not a homogenousgroup. Differences in FP use can be seen across andwithin provinces, urban/rural areas, and SES groups.Figure 6. Contraceptive Prevalence Rate (AnyMethod) by Province (KDHS, 2003)However, distance and travel costs were not a barrierfor all discussants, as some reported choosing to gofarther to receive the services they want or to protect5

PRELIMINARY FINDINGSJUNE 2009 DRAFTTable 2. Current FP Use and Unmet Need among Married Women (age 15–49) by Province, 2003 (KDHS)NationalProvinceTotal Urban Rural Nairobi Central Coast Eastern Nyanza RiftValleyWesternNorthEasternCurrent UseAny method (%)39483751662451253434

Discussion: The EQUITY ApproachPRELIMINARY FINDINGSJUNE 2009 DRAFTand relative wealth with urban areas, as even withinthese areas, there are segments of the urban and ruralpoor that are in greatest need of services. TheWhile overall improvements in healthcare systemspreliminary analysis of inequalities in FP useare desirable in most developing countries,presented in this brief shows that the lowest SESexperience has shown that health interventions willgroups are least likely to use family planning and alsonot reach the poorest groups without appropriateplanning, targeting, and oversight. 3have the highest unmet FP need.Care must betaken to identify the poor, understand their needs, andnderstanding the barriers to service accessassess their barriers to increased service access andUand use—Once the level of inequalit y is known,use. Building on this evidence, governments shouldpolicymakers must have an understanding of why theformulate targeted, pro-poor policies as theinequalities exist. The focus group discussionsfoundation of appropriate, responsive programs.summarized in this preliminary brief have identified“Targeting” directs scarce resources to those most inneed. 4key barriers such as misinformation andA “pro-poor” approach means that healthcaremisconceptions, lack of constructive malecosts are based on the client’s ability to pay; the poorengagement, sociocultural and religious beliefs,and nearly poor are protected from financial calamityhidden costs for services, and inadequate quality ofdue to a severe illness; and steps are taken to improvecare. These discussion findings can complementequitable access—both in terms of quality and theexisting data from the DHS to further explore reasonsgeographic distribution of services. 5for non-use of family planning.The Health Policy Initiative has designed thentegrating equity goals into policies, plans, andEQUITY Approach to ensure that health policiesIstrategies—Several countries, including Kenya,meet the needs of the poor. The approach calls for:aspire to alleviate poverty. To make this happen,specific policies, goals, strategies, resources, andngaging and empowering the poor—The poormonitoring mechanisms are needed. In Kenya, theE should be empowered to become involved in theHealth Policy Initiative has provided technicaldecisions that affect their healthcare needs. They aresupport to the government and in-country partners tobest able to speak to the challenges they face and todraft the new National Reproductive Health Strategy.provide insights to design appropriate solutions.The strategy calls for increasing “equitable access toThus, the poor have an important role to play inreproductive health services” and includes specific,problem identification, advocacy, planning, andtime-bound goals to: (1) reduce unmet FP needmonitoring. In Kenya, the Health Policy Initiativeamong the poor by 20 percent by 2015; and (2)involved the poor in problem identification throughincrease modern CPR among the poor by 20focus group discussions. The project has also workedpercentage points by 2015 (up from 12% in 2003).with in-country partners to organize policy dialoguebetween the poor and their representatives andargeting resources and efforts to reach theregional stakeholders in Nyanza Province. FurtherTpoor—Integrating equity goals into the nationaldissemination of findings from the focus groupstrategy is a positive step forward, and one that mustdiscussions has taken place at the community level inbe followed up with implementation and monitoringKisumu, Homa Bay, and Siaya Districts. Throughmechanisms. The need of the hour is to targetthese forums, the poor shared their views toward FPresources to reach areas of extreme poverty, such asuse and ways to improve service access.North Eastern and Nyanza Provinces, and the dry(and poor) northern parts of the country. Similarly,uantifying the level of inequality in healthcareQthere is a need to allocate resources to areas withaccess and health status—Getting the FP/RHpastoralist populations and to the urban slums inneeds of the poor on the national policy agenda firstmajor cities. The country should also design a healthrequires an understanding of the magnitude andfinancing strategy to ensure financing for the poor asurgency of the issue. Market segmentation analyseswell as strengthen and monitor the implementation ofbased on DHS data and poverty mapping can revealexisting fee exemption policies.the level of inequality and help to pinpoint areas ofgreatest need. In particular, it is important toielding public-private partnerships forrecognize that the poor are not a homogenous group.Yequity—Meeting the FP/RH needs of the poorIt is not enough to equate poverty with rural areas7

PRELIMINARY FINDINGSJUNE 2009 DRAFTrequires that countries make the best use of all theavailable public, private, donor, and NGO resources.As discussed above, the poor in Kenya account foronly about one-fourth of the clients of public healthfacilities. Strategies are needed to ensure thatsubsidized services (through the government orNGOs) reach the poorest populations and that theprivate sector serves clients that are more able to payfor services. The country should strengthen publicprivatepartnerships with the commercial sector, andexplore innovative models with NGOs—such ascommunity-based distribution, which worked well inKenya in the past—to reach underserved populations.Community discussions on family planning use among thepoor in Siaya District. Photo by Eric Ajwang.ConclusionFor the poor, lack of access to family planning andcontinued high fertility can mean fewer resources(e.g., money, time, attention) for each child, leadingto poor nutrition, ill health, and limited educationalopportunities—ultimately trapping this group in apoverty cycle. For the society, continued rapidpopulation growth will hamper Kenya’s ability tomeet the needs of its citizens and attain its health anddevelopment goals, such as those contained in theVision 2030 and MDGs. A range of policy andfinancing initiatives should be implemented to ensurethat the poor have equitable access to FP/RHservices. 6 No one strategy or program will expandaccess for all the poor and vulnerable groups inKenya, underscoring the need to address poverty andequity from multiple angles. Doing so will not onlybenefit the poor, but also the society as a whole.FOR MORE INFORMATIONHealth Policy Initiative, Task Order 1Futures Group InternationalThe Chancery Building, 3rd FloorValley Road, PO Box 3170Nairobi, Kenya 00100Tel: 254.20.2723951 / 254.20.2723952Web: http://www.healthpolicyinitiative.comThis brief was prepared by Task Order 1 of the USAID |Health Policy Initiative. It was produced for review by the U.S.Agency for International Development (USAID). The viewsexpressed in this publication do not necessarily reflect theviews of USAID or the U.S. Government.Task Order 1 is implemented by the Futures GroupInternational, in collaboration with the Centre forDevelopment and Population Activities (CEDPA), WhiteRibbon Alliance for Safe Motherhood (WRA), Futures Institute,and Religions for Peace.ENDNOTES1 Health Policy Initiative, Task Order 1. 2007. Inequalities in the Use of Family Planning and Reproductive HealthServices: Implications for Policies and Programs. Washington, DC: Futures Group International, Health Policy Initiative, Task Order 1.2 Based on the 1977/78 Kenya Fertility Survey (KFS), and the 1989, 1993, 1998, and 2003 Kenya Demographic and Health Surveys(KDHS).3 Gwatkin, D.R. 2004. “Are Free Government Health Services the Best Way to Reach the Poor?” Health, Nutrition, and Population (HNP)Discussion Paper. Washington, DC: World Bank.4 POLICY Project. 2003. “Targeting: A Key Element of National Contraceptive Security Planning.” Policy Issues in Planning and FinanceNo. 3. Washington, DC, Futures Group International, POLICY Project.5 Bennett, S. and L. Gilson. 2001. Health Financing: Designing and Implementing Pro-poor Policies. London: Department for InternationalDevelopment (DFID) Health Systems Resource Center.6 Health Policy Initiative, Task Order 1. 2007. “Approaches That Work: Health Equity.” Washington, DC: Futures Group International,Health Policy Initiative, Task Order 1.8