Primary health care facilities are pro-poor
The two poorest quintiles received about half of the public sector PHC benefits in both time periods. There were no significant differences in the distribution of PHC benefits in the private-not-for-profit sector between 2003 and 2007, although the 2007 results suggest a shift towards pro-poor distribution. The greater pro-poor distribution of public PHC benefits reported in 2007 could be attributed to a user fee reduction policy introduced in 2004, where variable user fees in government dispensaries and health centers were abolished and replaced with a flat rate of Kenya Shillings 10 and 20 respectively. Studies in low and middle income countries have shown that the poorest population tends to use PHC more than the rich [4, 10]. These results have led for calls to direct additional funds to primary health care services as a way of promoting equity. The Kenyan government regards primary health care facilities as an important part of the health system and various reforms have been implemented to ensure that primary health care facilities offer quality services (including transferring funds directly from the treasury to facilities' bank accounts to minimize delays experienced when they are channeled through the health ministry). While these funds are expected to promote access to PHC services for all, care should be taken to ensure that the poorest populations, who bear the greatest burden of ill-health, continue to benefit from these services.
Hospital level services are pro-rich, but larger disparities are recorded in outpatient compared to inpatient services
Hospital level services were pro-rich, except the private-not-for-profit sector that showed a pro-poor distribution in 2007. Outpatient services were more pro-rich than inpatient services in the public and private-not-for-profit sectors. These findings differ from others that have reported a more pro-rich distribution for inpatient compared to outpatient services [4, 16, 17]. The richest quintile received two-thirds and about a quarter of tertiary level outpatient and inpatient benefits respectively, while provincial and district hospitals mainly served middle-income groups. Health care resources in Africa are concentrated at the hospital level [4, 14, 18]. Kenya spends over 50% of the public health budget on hospitals services [14]; these resources, as clearly demonstrated by the findings, mainly benefit the two richest quintiles. Previous studies have argued that in countries where the private sector is well developed, government subsidies can be better targeted towards the poor, by diverting the demand for health care for the rich population to the private sector [4]. Our findings suggest that this is not easily achieved. Kenya has had a very developed private sector for the last two decades, but public hospital services remain pro-rich. Alternative strategies to ensure that resources allocated to public hospitals benefit everyone who needs them are required.
The public and private health sector recorded a similar magnitude of inequalities in 2003 but differences across sectors were observed in 2007
The distribution of total benefits in 2003 revealed a similar magnitude of inequalities across the three sectors under consideration. The richest two quintiles received more than half of total benefits in each sector. However, the distribution of health care benefits in 2007 clearly distinguished between the three sectors; the private not-for-profit sector showed a pro-poor distribution, public sector benefits approached equality, while the private for-profit sector was very pro-rich. Few studies have compared the distribution of benefits for the entire health system. The only study that documents distribution of benefits in both public and private sectors reveal wider inequalities in the private sector compared to the public sector [16]. Private health care facilities are perceived to have greater inequities than the public health system [3]. Our findings demonstrate that in some cases, the degree of inequalities can be similar in all sectors. It is not clear why this pattern was observed in 2003, considering that private services often charge higher fees than government facilities. What is clear though is that neither the public nor the private sectors catered for the needs of the poor in 2003, although the 2007 data suggest some improvements in public and private-not-for-profit sectors.
Government subsidy records a similar distribution
The distribution of government subsidy follows a pattern similar to the benefits, with the poorest population receiving a larger share of PHC subsidy compared to hospital level subsidy. When the subsidy is expressed as a percentage of households' consumption expenditure the poor receive a subsidy that accounts for a higher proportion of expenditure compared to the richest population. Although governments subsidize health services in many countries, evidence suggests that the rich benefit from government subsidies more than the poor. A study conducted in 21 countries revealed that the richest 20% of the population received 26% of total government subsidies, compared to 16% received by the poorest 20% [8]. In a review of the distribution of government subsidy on health, Chu et al. 2000 reported that public health expenditure was well targeted in 21 out of 38 studies and that the poorest 20% received more than the richest 20% when the subsidy is expressed as a percentage of their income or expenditure (i.e. progressive distribution). Sub-Saharan African countries performed poorly for all levels of care. In a country like Kenya, where there is a significant private sector, and where people access public services on the basis of ability to pay, questions regarding the role played by the public health system in addressing inequities remain.
The distribution of benefits is inappropriate
The poorest population is in greater need of health services than the richest population, and should therefore receive the largest share of health system benefits [3]. Results confirm that the poorest Kenyans have greater health needs, but they receive the least share of total health system benefits. Few studies assess whether the distribution of health system benefits match need for care. A study conducted in the United States reported that the distribution of public spending favored those with higher need for care and increased strongly with health need [19], while in South Africa the distribution of health sector benefits did not match need for care [16]. Countries should work towards restructuring their health systems in a manner that removes the main barriers of access (including but not limited to affordability, availability and acceptability) to ensure that all people can access care when they need it.
Limitations
This study has several limitations. First, BIA does not account for differences in quality of care. Quality differences exist between facilities. The poorest population might be using lower quality services than the richest population, suggesting that benefits received by the poor would be much lower if quality differences were accounted for. Second, seasonality is an important factor influencing levels of self reported illnesses, treatment seeking behavior and health care costs [20, 21]. The analysis did not account for seasonal variations and therefore annual utilization rates may be overestimated (underestimated) depending on the household surveys timings. Thirdly, outpatient days were converted into inpatient day by divided by three. This approach can have implications for cost levels. Fourthly, need in this study is measured through SAHS. This measure does not tell the equidistance between categories, although it has been shown that standardized measures of need compare well with SAHS categories [22]. Finally, multiple measures of need exist, some of which suggest that the rich might have greater need in relation to non-communicable diseases. Future studies should compare appropriateness of health system benefits distribution using different indicators of need.