Affordability is also commonly known as financial access [
33,
34,
37]. The cross-sectional survey identified lack of money as a major barrier for seeking treatment: 61.5% of individuals who did not seek treatment reported that cash shortage was the main barrier (Table
1). Individuals who treated fevers were asked if they had enough money to pay for treatment. In 40.0% of all treatment actions taken, money was not readily available at the time of seeking treatment (Table
2). Lack of cash was common among both individuals self-treating using drugs from the shops (38.9%), and those that sought treatment in the formal sector (41.8%). Where cash was not readily available households adopted different coping strategies (Table
2). Borrowing was the main source of cash for treatment (25.4%). Money was mainly borrowed from friends and neighbors (38.5%), and from relatives (36.9%). Other coping strategies included being treated on credit at a health facility (17.6%), gifts (10.1%) and sale of assets (10.0%). Sale of labor was hardly used as a source of money to pay for treatment, but it was the main source of money for paying debts that arose due to the treatment-seeking (41.3%). Assets were also frequently sold in order to pay for illness related debts (41.3%).
Table 2
Sources of money to pay for treatment.
Had enough money to pay for treatment | |
• Yes | 613 (60.0) |
• No | 409 (40.0) |
Sources of money to pay for treatment | |
• Cash savings | 636 (62.2*) |
• Borrowing | 260 (25.4) |
• Gifts | 103 (10.1) |
• Casual labour | 34 (3.3) |
• Sale of assets | 102 (10.0) |
• Credit at health facility | 180 (17.6) |
• Waivers | 12 (1.2) |
• Other | 26 (2.5) |
Money borrowed/credit paid back at the time of survey? | |
• Yes | 166 (37.7) |
• No | 274 (62.7) |
Sources of cash to clear debts | |
• Cash | 15 (9.0) |
• Casual labour | 69 (41.3) |
• Sale of assets | 69 (41.3) |
• Gifts | 12 (7.2) |
• Other | 12 (7.2) |
Qualitative data also identified affordability as a major barrier to access. Affordability related barriers reported in the FGDs included:
Cost of treatment
Costs of treatment as a barrier to access was a predominant theme in all FGDs. High costs reportedly prevented people from seeking effective treatment despite knowing that malaria should be treated with appropriate anti-malarials. Women experienced particular problems raising money for treatment. Alternative cheap and ineffective sources of treatment were often sought:
"There is this drug called coartem which is very expensive [referring to the first-line anti-malarial in Kenya]. Its price is about 900-1200 Kenya shillings (KES). When you get a prescription to buy such a drug, given our economic situation, one cannot afford to buy it, even when you are seriously ill. That is why we have to resort to other means like panadol [pain reliever] if only to get relief. We are even more disadvantaged as women because our sources of income are limited compared to men's." (FGD, Female)
"Sometimes parents do not have money to take their children to a health facility. We buy medicines like panadol [pain reliever] which we use to bring the fever down. Then we believe that the child has recovered, but that is not true...malaria continues to gain strength [meaning becomes severe]." (FGD, Male)
Study participants reported that people who lacked money to pay for treatment at the government facilities were not given appropriate anti-malarials. This impacted on people's perceptions of quality of care, acceptability of services and contributed to poor drug adherence:
"We do not get proper treatment because money is required at the dispensary.., but if you do not have the money, you cannot be treated. If you have less money, then you will be given drugs that cannot cure you." (FGD, Female)
"If you do not have enough money, they [health workers] give you a one-day dose and ask you to go with money the next day to collect the remaining dose...But where is the money? They give us an under-dose which is not good" (FGD, Male)
Other affordability issues reported included cost of transport and waiting time:
"You can find a household with four ill children. Giving them treatment becomes difficult. First, transporting them to the facility is a problem, raising money to pay for treatment is difficult, and when you get to the dispensary, you wait the whole day." (FGD, Male)
Seasonality of illness and income sources
Seasonality is an important factor influencing treatment-seeking for malaria. In all FGDs, seasonality of malaria transmission and income sources were identified as barriers to access. FGD participants reported that malaria mainly occurs during the peak agricultural season when people are busy in the farms, and when most make a large proportion of their annual cash income. Being ill during this period therefore had significant impacts on people's income and sometimes led to failure to treat illness in order to continue with income generating activities. Also, the queues at the health facilities were reportedly longer than in other times of the year, and drug supplies were felt to be inadequately adjusted to meet the high demand in the peak season:
"There are constant stock-outs during the rainy season because there are many ill people. We suggest that the quantity of drugs supplied during the rainy season be increased to match the rising number of illnesses." (FGD, Male)
"Getting proper treatment is usually a problem during the wet season because many people fall sick. The dispensaries are also full during this period." (FGD, Male)
"Sometimes you are sick but you just have to continue working because you have children looking upon you for food. If you do not work, you will not harvest or get any money to buy food for the children." (FGD, Female)
Incomes were also reported to be seasonal and unreliable, and most people struggled to make ends meet during the difficult months of the year. During this period, seeking effective treatment was beyond households' budgets:
"The months from October to February are very dry and most of us have nothing to do to raise money. You can look after someone's goat for a day to get KES 20, but that is nothing for anyone who has a family to feed, let alone take a child to a health facility" (FGD, Male)
"There are particular months when it is difficult to get money. During this time, there is no rainfall and therefore no farming activities going on...there is no water for our vegetable farms.., there is no money". (FGD, Female)
In addition to formal charges, people occasionally reported giving health workers some money to enable them receive 'good' treatment quickly. These informal charges were sometimes high, increased the cost of treatment, and acted as an access barrier:
"Some of them ask for tea [meaning under-the-counter payment] of about KES 50 or KES 100 if one is to get good drugs and faster treatment." (FGD, Male)
Acceptability is sometimes referred to as cultural access [
32]. It involves the interactions between the health care system and service users, provider and patient attitudes, and expectations of each other [
32,
51]. It also includes the compatibility between lay and professional health beliefs, patients' perceptions of effectiveness of treatment, and the extent to which their constructions of health and healing match health workers' understanding of these issues [
32]. The cross-sectional survey collected data on individuals' satisfaction with the quality of services received at formal health care providers as an indicator of acceptability. The results indicated that 311 individuals (55.0%) who sought treatment from formal health care providers were satisfied with the services; 209 (36.9%) were dissatisfied and; 45 (8.0%) were indifferent. The main reasons given for the dissatisfaction were the quality of drugs received (23.2%) and lack of drugs (23.2%); low confidence in staff ability to offer good quality treatment (17.8%), and lack of diagnostic tests (10.1%). Satisfaction with services was linked primarily to availability and effectiveness of drugs, confidence in staff, and short waiting time (69.1%, 13.1% and 3.6% respectively).
Qualitative data provided more insights on acceptability related determinants of access:
Provider-patient interactions and perceptions on health workers' attitudes
Provider and patient attributes, expectations, beliefs and perceptions were identified as key factors influencing acceptability of formal health care services. In Bondo district, older clients reportedly found it difficult to accept treatment by youthful providers, associating young health workers with inadequate training and poor quality of care, including disrespectful behaviour. In Gucha and Kwale districts there were similar concerns about community health workers (CHWs). Several comments suggested that these concerns might be linked to broader problems of distrust in health workers and dissatisfaction with the replacement of older more familiar staff:
"It is their qualifications that we doubt.... The young boys are not good but the older providers who worked here before were good. We feel the drugs are there but they do not know how to diagnose diseases and administer appropriate medication. They do not know how to hold the syringe; they hold it like it is some pen for writing" (FGD, Female).
"We have these people who are CHWs but they give treatment at the health facility. When you go there, they are the ones to inject you and when you get concerned and ask him 'we have just come with you from home, are you qualified to treat me?' He tells you to stay there untreated. And when you go to the qualified doctors to complain, they say that if you think the CHWs are not qualified, you should bring your own doctor to the dispensary. At this time you keep quiet and know that you are not going to get proper treatment." (FGD, Female)
In many FGDs across the four districts, health workers were reported to be inconsiderate and uncaring, and these negative opinions apparently impacted on people's willingness to seek care at public facilities. Although in some cases health workers were said to lack commitment and not to have the patients' interests at heart, others felt the health workers were not solely to blame; that their attitudes resulted from broader health system factors associated with high work load and low remuneration:
"The other thing is the attitude of the health workers. They do not care about the patients. It is like they do not have a human heart or blood. They sit doing nothing all day...we have to plead with them to attend to us." (FGD, Male)
"It is because [referring to why quality of care is low] the staff are few and the overwhelming number of patients makes it impossible for them to give due attention to each patient. They are also paid very low salaries yet they are trained...they should be paid well." (FGD, Female)
"We cannot blame him [the provider] because he does his best. Not even leaving for tea break or lunch...he treats non-stop" (FGD, Male)
Perceptions of illness causes, effectiveness of treatment, and distrust in quality of care
Malaria was reported to be a common problem in all FGDs across the four districts. The causes of malaria were not always clear, with participants in about half the FGDs in all districts attributing it to dirty water, coldness or weak blood. High awareness of the need to treat malaria in formal facilities was demonstrated in all FGDs. While people did not always use anti-malarials to treat fevers, they attributed this to affordability and availability barriers rather than lack of awareness of appropriate drugs. People reported that they could easily diagnose malaria but that their diagnoses sometimes conflicted with those of health workers. Even when blood tests were reported as negative, patients reported that they sometimes bought malaria drugs from shops or chemists anyway. In such cases this may mean that additional, possibly unnecessary, costs are incurred by households:
"I was told that I did not have malaria, but when I went to the chemist and bought malaria drugs for KES 80, I got better. The following day I could attend to my duties without much difficulty." (FGD, Male)
"Sometimes you feel that you are suffering from malaria but when you visit the hospital, the tests show that there is no malaria in your body. You are given panadol which cannot cure you. If you have money, you will go to buy malaria drugs." (FGD, Male)
Poor adherence to treatment
Poor adherence to treatment emerged as a barrier to effective treatment. Where drugs were available and issued to patients at health facilities, it was reported that people did not always adhere to the dosage, either to save the medicine for future use, or because drug administration timings were inconvenient, especially for mothers who left their children behind to go and work on the farms or to look for casual labor:
"Some parents do not follow the instructions they are given by providers. Many parents fail to administer the full dose to children as soon as they notice signs of recovery. This happens mainly for the syrups...mothers want to keep them for another day [meaning another illness episode]." (FGD, Male)
"It is the commitments that mothers have that make them forget to give their children medicine. When the child feels better, her mind switches to other things such as the ever pressing need to cultivate vegetables by the lake. Once she is by the lake she will not return home to give the child medicine." (FGD, Female)
Unavailability of services and desperation were other factors that contributed to poor adherence. People reported that patients failed to complete the dosage, either because the medicine was not available at the facility, or the health workers did not open the dispensary due to other commitments:
"Treatment can be effective, but for it to be effective one has to comply. But when the health worker recommends, for example three injections, the patient ends up receiving one because the provider is either absent or the medicine is not available." (FGD, Male)
"At times your neighbor might give you some drugs that they are not using, and you take those drugs not knowing what they treat or whether they are expired." (FGD, Female)
Availability (or physical access) refers to whether health services and providers are supplied in the right place at the right time, and whether the services offered correspond with population's needs [
32,
33,
35,
37]. Key availability themes that emerged were facility opening hours, drug shortages, and location and organization of health services.
Facility opening hours
One out of the 34 facilities covered was reported to operate 24 hours, seven days a week. Most opened at 8.00 am every day (n = 28), and closed at 4.30 pm (n = 19). In 20 facilities, health workers reported being contactable for emergency services out of hours through mobile phones. In 10 facilities, the in-charge reported having had to close the facility, either to attend a workshop (n = 3), when summoned to the district headquarters by the district medical officer for health (n = 2), or during annual leave (n = 3). These facilities were operated by only one health worker and, consequently, there was no one to offer services in their absence.
The limited operating hours were repeatedly reported as barriers to access in all districts, especially during the weekends when primary health care facilities remained closed:
"Sometimes the illness starts in the evening or during the weekend when the dispensary is closed, so we are forced to buy drugs from the shops. If it is a serious illness, you suffer throughout the weekend or go to the district hospital if you have the money, but this is rare. Few people have money to go to the district hospital." (FGD, Male)
Closely related to official opening hours is that facilities apparently often do not open on time. Community members attributed this primarily to poor work ethics among the health workers and inaccessible roads during the wet season:
"The provider comes to the facility at his own time; he opens late everyday and closes early. There is no consistent time of opening or closing the facility and over the weekends there is no one to treat us." (FGD, Male)
"The provider leaves early because there is only one vehicle plying this route and if he misses it, there are no other means to town. During the rains, the roads are impassable and at times the dispensary nurse-in-charge cannot get here" (FGD, Female)
Others felt that health workers did the best they could under the circumstances. Some facilities were understaffed, some had only one health worker, and in their absence the health facilities remained closed or were operated by community health workers.
"One problem is that we have only one health worker who leaves on Friday early afternoon and reports back to work on Monday afternoon. So from Friday through to Monday we do not have anyone to treat us. Sometimes he goes for a seminar the whole week and during this period the dispensary remains closed" (FGD, Female)
Drug shortages
Drug availability is another key factor influencing access to treatment. Individuals who sought treatment from public health facilities in the two weeks preceding the survey were asked if they received all the prescribed drugs from the hospital pharmacy and whether or not they were issued with a prescription to buy drugs from a private chemist. The results indicated that 95 (30.0%) of people who visited public health facilities did not get drugs from the hospital pharmacy and were issued with a prescription to buy drugs elsewhere. Of these, only 31 (32.8%) individuals bought the prescribed drugs. Among exit interview participants, 140 (38.8%) did not receive drugs from the facility because they were out of stock.
Persistent shortages of anti-malarials in public health care facilities discouraged people from seeking effective treatment. Participants in all FGDs were very vocal about chronic drug shortages in the public health facilities and the implications this had on affordability and treatment-seeking behaviour:
"When you take your child to the health facility...first you queue and pay for registration, then you are sent to the first room where you pay for the rubber stamp, after that you are told to go to the laboratory, where again they tell you to pay for the tests, then you get to the pharmacy and you are told there are no drugs. You go through this long process and use all the money, but all you have are receipts. What are you going to do with receipts? They should have left you with your money to buy panadol or to go to another health facility." (FGD, Female)
"The problem is that when you go to the hospital, the health worker says there are no drugs, so all he does is to write prescriptions or refer you to the district hospital. If you have no money for drugs, where will you get money to go to the district hospital? That is why malaria is killing us...You will suffer until God decides to take the illness away." (FGD, Male)
There were strong perceptions that health workers' diverted public drugs to private chemists and clinics where they often referred people to buy the prescribed medicines. This behaviour, it was reported, was responsible for the chronic drug shortages in public health care facilities:
"The health workers at the dispensary often ask patients to go to their homes later in the evening or during the weekend for treatment because there is no medicine at the dispensary but they use drugs they have taken from the dispensary." (FGD, Male)
"He opened a drug shop at the market and would steal our drugs to sell to us at his shop until he was transferred..." (FGD, Female)
Shortage of anti-malarials in the health facilities was also attributed to Coartem- the 1st line drug in Kenya- being expensive and, therefore, the government could not afford to restock the drug on time:
"The drugs at the dispensary are not good. We do not get well after taking them. I think it is because the price of the new drug [referring to ACT] is very high, and so it is never in stock. The malaria drug that is sometimes in stock is fansidar [SP], which no longer cures malaria." (FGD, Male)
While many apparently blamed the health workers, a few pointed out that it was difficult to confirm whether the problem was in the supply of drugs from the government or the behaviour of the health workers. Making health facilities more accountable to the community was identified as a potential mechanism for reducing and/or confirming suspicions of drug theft:
"It is difficult to verify these claims. Nobody knows whether the government brings drugs and no one checks the pockets of the health workers to confirm that they steal drugs." (FGD, Female)
"The community should have access to records showing the amount of drugs received and how they have been dispensed. This way, we can know if they [health workers] steal drugs or not." (FGD, Male)
Location of health facilities
Physical location of health facilities in relation to service users and availability of transport influence where, when and what sort of treatment is sought. In almost all FGDs across the four districts, participants reported that they had to travel for long distances to a health facility. The poor road network and limited sources of transport further compounded the problem. Long distances also involved extra time and financial costs:
"There is only one vehicle that passes here at 6 am and at 3 pm to and from town respectively and when one misses it, then one has to wait till the following day.... We have nothing to do in case of an emergency" (FGD, Male)
"It is the distance from health facilities that makes it difficult for us to seek good quality treatment fast. It is not easy to get a vehicle to the facilities and meet the costs of transportation as well as for the treatment at the same time. Sometimes we use bicycles but it is too far" (FGD, Female)
Organization of health care services
The way health care facilities are structured may promote or hinder use of health care services and thus act as a barrier to effective malaria treatment. Seeking treatment from public health facilities was reportedly an unnecessarily long and frustrating process, involving a number of stages. Patients typically: pay the registration or card fees; take the card for stamping and sometimes pay a stamping fee; see the health worker who might recommend a parasitaemia test; go to the laboratory and then return to the health worker with the results; and finally go to the pharmacy to receive available prescribed drugs. Each stage can involve significant queuing and delays, making the system cumbersome, with negative implications for patients trust in the providers' and in the health system.