One in four patients with chronic respiratory diseases may face catastrophic health costs in Kenya

A quarter of people seeking care for symptoms of chronic respiratory diseases in Kenya may incur 'catastrophic' health costs, new research published in The Lancet Global Health has found.

A study of almost 300 adults accessing treatment for respiratory symptoms across five health facilities in Meru County, Kenya, found that over a quarter (26%) had 'catastrophic health expenditure' (CHE, defined as over 10% of their household's monthly outgoings) relating to their illness and seeking care.

The severe economic burden included medical costs, such as for consultations, tests, medicines to diagnose and treat their condition, and also non-medical costs, such as travel of the unwell person – and sometimes their carer - to and from the health facility. This burden is occurring despite Kenya having a national insurance scheme, which is currently being reformed, because most study participants were not members of the scheme. Even amongst the minority of participants who were members of the scheme, most did not use it to pay for their care.

Financial outcomes were even worse for women, those from lower socio-economic backgrounds, those accompanied by a carer, or those accessing healthcare in better equipped but more distant hospitals rather than smaller, local primary health facilities. Nearly all (95%) of the participants had resorted to financial coping strategies, including dipping into savings or borrowing money to pay for their illness and care seeking.

The study was led by Liverpool School of Tropical Medicine (LSTM) and the Kenya Medical Research Institute (KEMRI), and delivered through the International Multidisciplinary Programme to Address Lung Health and TB in Africa (IMPALA).

Dr. Tom Wingfield, Deputy Director of Liverpool School of Tropical Medicine's Centre for TB Research and senior author on the paper, said: "To our knowledge, this is the first study to estimate the burden and drivers of catastrophic health expenditure amongst people seeking care for symptoms of chronic respiratory disease in Kenya. We have shown that the financial burden associated with illness and accessing healthcare is substantial, especially for people who are already vulnerable, and associated with financial shock including using savings, borrowing money, or selling household items. It doesn't need to be this way.

"The roll-out and refinement of the new Social Health Insurance Fund (SHIF) across Kenya represents a golden opportunity to improve the effectiveness, equity, and reach of health insurance for everyone, so that being ill and seeking care does not make people worse off."

Chronic respiratory diseases, such as asthma and chronic obstructive pulmonary disease (COPD), are among the four main non-communicable diseases that account for 80% of premature deaths related to NCDs globally.

One of the UN's Sustainable Development Goals is to reduce premature deaths due to NCDs by 30% by 2030, through strengthening the primary health-care system, increasing the coverage of social protection, and working towards reaching universal health coverage to reduce the out-of-pocket costs, lost income, and CHE of people who are unwell and seeking care.

CHE disproportionately affects the most economically vulnerable households, causing them to resort to financial coping strategies including using savings, borrowing money, taking loans, and selling household assets - a medical poverty trap that compounds their impoverishment. Between 2015 and 2017, CHE incidence increased from 12.7% to 13.2%, globally.

This study provides timely evidence to support health financing decision-making in Kenya, at a crucial time when the social health insurance system is being reformed. The current Social Health Insurance Fund (SHIF) plan contains provision for covering chronic conditions and outpatient care. There is, however, a critical need to pay attention to aspects that hinder full utilization of insurance services for example due to non-payment of premiums, lack of information, or potential clients not having the required identification documents to register. Kenya has a huge informal sector economy: about 83% of the total workforce. A defining characteristic of the informal sector economy is unpredictable incomes, and steep trade-offs that people have to weigh up between attending healthcare facilities and income generating opportunities.

There is an urgent need for financing models that are responsive to these realities and enhancement of service delivery at the primary care level to increase service utilization at the local health facilities, and minimize travel costs."

Dr. Stephen Mulupi, Head of Research at LCVT Health, a Kenyan NGO, and first author of the study

Dr. Mulupi and Dr. Wingfield emphasize that the findings underline the importance of affordable and effective health insurance or universal coverage to reduce CHE and the burden of chronic respiratory conditions.