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Table 1 Development of health care financing policies in Kenya

From: Viewing the Kenyan health system through an equity lens: implications for universal coverage



Equity impacts

Colonial period

User fees in all public facilities

Discriminative policy against Kenyans, imposed by colonial government


User fees initially introduced continued to exist for two years after independence

Negative impacts of affordability and utilisation of health care services


User fees removed at all public health facilities. Health services provided for free and funded predominantly through tax revenue

Potential for equity provided there are mechanism to ensure that the poor benefit from tax funded system


User fees introduced in all levels of care.

Negative impact on demand for health care especially among the poorest population; decreased utilisation including essential services like immunisation


User fees suspended in all public health facilities. Waivers and exemption put in place to protect the poor and vulnerable. Failure linked to poor policy design and implementation.

Increase in utilisation patterns, confirming previous reports that user fees are a barrier to access.


User fees were re-introduced in 1991, through a phased implementation approach stating from hospital level. Children under five, special conditions/services like immunisation and tuberculosis were exempted from payment. User fees continued to exist in Kenya at all levels of care.

User fees major barrier to access, high out-of-pocket payment, catastrophic impacts, and negative implications for equity.


User fees abolished at dispensaries and health centres (the lowest level of care), and instead a registration fees of Kenya shillings 10 and 20 respectively was introduced. Children under five, the poor, special conditions/services like malaria and tuberculosis were exempted from payment.

Utilisation increased by 70%; the large increased was not sustained, although in general utilisations was 30% higher than before user fee removal. Adherence to the policy has been low, due to cash shortages


All fees for deliveries at public health facilities were abolished

No data on extent to which policy was implemented and no evaluation has taken place.


A health sector services fund (HSSF) that compensates facilities for lost revenue associated with user fee removal introduced. Dispensaries and health centre receive funds directly into their bank accounts from the treasury.

Possible positive impacts on adherence to fee removal policy and equity.