The role of community-based organizations in household ability to pay for health care in Kilifi District, Kenya
1Kenya Medical Research Institute (KEMRI)/Wellcome Trust Collaborative Research Programme, Centre for Geographic Medicine Research, Kilifi, Kenya.
2Medecins Sans Frontieres – Holland, Plantage Middenloan 14, P.O. Box 10014, 1001 EA Amsterdam, The Netherlands.
3Centre for Health Policy, University of Witwatersrand, Johannesburg, South Africa and London School of Hygiene and Tropical Medicine, London, UK.
*Corresponding author. KEMRI, P.O. Box 230, Kilifi, Kenya. Tel: +254 41 522063. Fax: +254 41 522390. E-mail: SMolyneux{at}kilifi.kemri-wellcome.org
There is growing concern that health policies and programmes may be contributing to disparities in health and wealth between and within households in low-income settings. However, there is disagreement concerning which combination of health and non-health sector interventions might best protect the poor. Potentially promising interventions include those that build on the social resources that have been found to be particularly critical for the poor in preventing and coping with illness costs. In this paper we present data on the role of one form of social resource—community-based organizations (CBOs)—in household ability to pay for health care on the Kenyan coast. Data were gathered from a rural and an urban setting using individual interviews (n = 24), focus group discussions (n = 18 in each setting) and cross-sectional surveys (n = 294 rural and n = 576 urban households). We describe the complex hierarchy of CBOs operating at the strategic, intermediate and local level in both settings, and comment on the potential of working through these organizations to reach and protect the poor. We highlight the challenges around several interventions that are of particular international interest at present: community-based health insurance schemes; micro-finance initiatives; and the removal of primary care user fees. We argue the importance of identifying and building upon organizations with a strong trust base in efforts to assist households to meet treatment costs, and emphasize the necessity of reducing the costs of services themselves for the poorest households.
Key Words: Illness, ability to pay, social relations, community-based organizations, community financing, user fees, micro-finance, trust
Accepted for publication 18 June 2007.