Assessing the impact of removal of user fee for maternal health services on universal health coverage in Kenya

Publication Details

3ie Funded Evaluation, PW3.04. A link to the completed study will appear here when available.

Timothy Abuya, Ben Bellows
Institutional affiliations
None specified
Grant-holding institution
None specified
Sub-Saharan Africa (includes East and West Africa)
Health Nutrition and Population
Health Financing, Insurance and User Fees, Primary Health- including reproductive health
Gender analysis
Health Financing, Insurance and User Fees, Primary Health- including reproductive health
Gender analysis
Equity Focus
Evaluation design
Mixed Methods, Others
Ongoing 3ie Funded Studies
3ie Funding Window
Policy Window Round 3


The study assesses the impact of changes in user fee policies on utilisation of maternal healthcare services in Kenya.


In many parts of Sub-Saharan Africa, considerable efforts have been made to identify barriers to seeking health care with the aim of increasing access to services, particularly for disadvantaged populations.  Some of the potential barriers include perceived low quality of service, socio-cultural factors, non-availability of health services, distance and travel cost, and out-of-pocket expenses.   The out-of-pocket cost of seeking health care is a major barrier, especially among the poorest. Despite these observations, many African countries introduced user fees in the 1980s at the primary health care level. In the past decade though there has been a policy shift towards the removal of user fees at the point of service.

Research questions

  1. What is the impact of user fees (removal or introduction) on public, private and home-based deliveries among the poorest two quintiles?
  2. Has devolution of responsibility for maternity care to counties affected facility-based deliveries?
  3. Does the replacement of user fee with cost reimbursement, combined with or without a voucher, impact the use of facility-based maternity care?


Intervention design

Kenya has been making efforts to provide health services free of charge. The post-colonial government made universal health care a major policy goal by abolishing user fees in 1965 two years after independence. This continued up to 1988, when the Kenyan government yielded to international pressure to reintroduce user fee and other major reforms in the health sector. Inadequate financial resources and declining budget were some of the reasons given to justify the re-introduction of user fee.

The user fee was again suspended in 1990 and re-introduced in phases in 1991. Following the re-introduction in 1991, fee was charged only for individual services like drugs, injections, and laboratory services.  

In 2007, the Ministry of Health rededicated itself to expanding free maternal health services in public facilities, including hospitals.

In addition to the removal of user fees, the Kenyan Government has recently tested several innovative strategies to increase access to services for the poor and, in several pilot projects, improve financing for facilities where user fee has been removed.

Theory of change

Currently the government seeks to develop a free maternity care policy.   However, the funding for the policy needs to be adequate to  ensure that services are not interrupted and that the gains from the removal of user fee are realised.

Evidence from literature suggests that gains from increased utilisation are often short-lived. If sufficient funds are not available gains are eroded as issues of ensuring sufficient staffing and quality emerge, moreso when free services significantly increase demand for services. Facilities may resort to charging user fees again, formally or informally. In summary, studies have concluded that user fee removal ought to be accompanied by alternative financing mechanisms to achieve long-term success.

The theory of change proposes that user fee removal accompanied by the introduction of adequate alternative financing mechanisms can generate sustainable improvements in utilisation of services and other health outcomes of interest..

Evaluation design

The study addresses two important gaps in the evidence base.  First, by taking a long time period (18 years with approximately 216 monthly intervals 1995-2014) and using an interrupted time series approach, the study will examine not only short-term impact but also long-term outcomes of whether different attempts to remove user fee in the same country have resulted in different outcomes. 

Second, by including outcomes on equity and private and/or public mix, the proposed study will inform the impact of removing user fee on both public and private sectors and its potential implication for moving African health systems toward universal health care coverage.

The proposed tracer service is facility-based deliveries within the broader maternal and child health services. A second tracer service would be the completeness or coverage of antenatal care services as reported in the demographic and health survey pregnancy and postnatal calendar. This measure could proxy for changes in ANC quality over time.

The proposed study has the advantage of using a mixed methods approach to allow for a more complete picture of the environment in which user fee removals are being implemented and therefore generate better model specification.  Additionally, the interrupted time series (ITS) model has the advantages of detecting delayed or intermittent programme effects and can determine if these changes are temporary or permanent. 

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