Provision of health care by the state in Kenya: a fragile state versus civil society

Abstract

This dissertation focuses on two major development actors in Africa as providers of health care: the state versus civil society (non-state actors). Using the case of Kenya, it examines the limitations of the state in the provision of health care, policy reforms intended to improve the performance of the health sector, and civil society's role in this process. More specifically, the dissertation focuses on the availability of, and accessibility to, different types of state and non-state health facilities in Murang' a district. Use of such facilities varies widely depending on a number of factors examined in this dissertation. The study is based on survey data of 504 women in Murang'a district. Using the survey, the study simulates logistic regression models to estimate utilization of four types of health facilities identified in the district and respondents' perception of user fees. Additionally, secondary data from publications by the government of Kenya and international organizations are used to supplement survey data. This study has several findings related to policy reforms in Kenya's health sector. For example, the study found that increasing public revenue for health through user fees is not a panacea for Kenya's health crisis. Unless non-financial constraints are first addressed, the potential of user fees will not be realized in Kenya. Further, the study reveals that despite the controversial arguments on the net effects of user fees, affordability of user fees is not a significant determinant of utilization of public health facilities in Murang' a. Importantly, the introduction of user fees in the district tends to significantly boost the utilization of mission hospitals. In general, the findings of this study suggest that marginal charges at public health facilities are unlikely to significantly reduce utilization of these facilities. Qualitative data suggest that if efficiency and quality problems were first contained, the Kenyan state could successfully boost its capabilities in the provision of health care by selectively adopting a cost -sharing policy. Last, during the advent of the user fees policy, the number of private clinics in Murang'a has increased drastically. Their utilization now tends to surpass that of corresponding government clinics. But in general, since non-state providers charge relatively high prices for their services, non-state facilities should not be considered as a substitute for public health facilities in Kenya.