Photo: Sjors737 - Dreamstime.com. Sexual & Reproductive Health Commodities: Measuring Prices, Availability & Affordability

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1 Photo: Sjors737 - Dreamstime.com Sexual & Reproductive Health Commodities: Measuring Prices, Availability & Affordability Data Collection Report Kenya 2017

2 Sexual & Reproductive Health Commodities: Measuring Prices, Availability & Affordability Data Collection Report Kenya 2017 Written by: Gaby Ooms Research Officer Health Action International Gemma Buckland Merrett Senior Research Manager Health Action International For correspondence, please Published by: Health Action International Overtoom 60 (2) 1054 HK Amsterdam The Netherlands Licensing: This report is licensed under the Creative Commons Attribution-NonCommercial 4.0 International Licence. To view a copy of this licence, visit This report is part of Health Action International s contribution to the Health Systems Advocacy Partnership.

3 Table of Contents 1. Introduction Data Collection Results Overall Availability of SRHC 3.2 Availability of Selected SRHC by Sector 3.3 Stock-out Days 3.4 SRHC Prices in Public, Private and Mission Sectors 3.5 SRHC Affordability in Public, Private and Mission Sectors 3.6 Stakeholder Interviews 4. Discussion Appendices Appendix A SRHC Surveyed 5.2 Appendix B SRHC Availability 5.3 Appendix C SRHC Stock-out Data 5.4 Appendix D SRHC Prices and Affordability Data 5.5 Appendix E SRHC Access: Qualitative Data Analysis 3

4 1. Introduction Good sexual and reproductive health (SRH) is a state of complete physical, mental and social well-being in all matters relating to reproduction for both men and women, including adolescents. Maintaining good SRH means people need access to accurate information and safe, effective, affordable and acceptable contraception methods of their choice. They must be informed and empowered to protect themselves from sexually transmitted infections and, when necessary, receive timely and affordable treatment. And when they decide to have children, women must have access to services that ensure they have a fit pregnancy, safe delivery and healthy baby. Every individual has the right to make their own choices about their SRH and family planning. National policies on medicine pricing and procurement strategies are needed to ensure medicines are affordable and available. While policies are also greatly needed to improve health infrastructure, health education and financing are further required to ensure the rational use of medicines. Even in the face of weak infrastructure and gross inequality that underpins poverty prevalence, improvements in access can be achieved. However, without reliable information on medicine prices and availability, governments are working in an evidence vacuum. This restricts their ability to construct meaningful policy and properly evaluate the impact of any policy interventions. Reliable information is also a useful means of comparison between countries with similar health budgets for knowledge transfer and learning. Thus, in order to develop evidence-based policies, robust data is required. The Health Action International (HAI) World Health Organization (WHO) methodology to assess the price, availability, and affordability components of medicines provides valuable data. To date, the methodology has not specifically targeted commodities for SRH. HAI has now adapted the methodology to focus on a specific set of sexual and reproductive health commodities (SRHC) 1,2. The objective of the survey is to generate reliable information on the price, availability and affordability of selected important commodities in the SRH supply chain, with the ultimate goal of improving access to affordable medicines for all. The methodology uses a crosssectional design with quantitative methods and a semi-structured questionnaire adapted from the standardised HAI WHO methodology, Measuring Medicine Prices, Availability, Affordability and Price Components (2 nd Edition). It allows data on the availability and outof-pocket patient prices of SRHC in the public, private and mission/other sectors to be collected. It also assesses health provider perspectives on access to SRHC beyond the medicines supply chain. The method facilitates rapid and reliable data collection and enables price and availability indicators to be compared within and between individual countries. 1 Please refer to the Sexual and Reproductive Health Commodities: Measuring Prices, Availability and Affordability methodology and data entry manual (1 st editions) for a full description of the methodology used for data collection. 2 For a full list of the commodities surveyed, see Appendix A. 4

5 The following report presents the results of the survey carried out by HAI and in-country partners (Medicines Transparency Alliance [MeTA] Kenya) during September 2017 in Kenya. The report provides data relating to the following questions: What price do people pay for SRH medicines? Do the prices and availability of the same medicines vary across the public, private and mission sectors? How affordable are medicines for ordinary people? What do health providers see as the main barriers to accessing medicines? The following report should be used to highlight potential areas for intervention to improve access to SRHC and monitor changes to access over time in the country of study. 5

6 2. Data Collection This report presents data from the initial roll-out of the HAI research methodology, SRHC: Measuring Prices, Availability and Affordability, in Kenya. The methodology used for the data collection follows the first version of HAI s SRHC data collection manual, produced in Please refer to this manual for all details on the methodology followed for data collection. Data collectors were trained in Kenya in August Data collectors visited facilities at health post levels and above belonging to public, private and mission sectors in both urban and rural areas. The selection of provinces to survey was random to provide a representative picture for the country. The districts selected for data collection were: Meru, Nairobi, Mombasa, Uasin Gishu, Kisumu and Western (Kakamega and Vihiga). A total of 120 facilities were surveyed across public, private and mission sectors. The distribution of these facilities is outlined below. Urban Rural Total (N) Public Private Mission Total Table 1: Distribution of surveyed facilities. 6

7 3. Results The following sections contain data analysed from Section A of the methodology, SRHC: Measuring Prices, Availability and Affordability, which measures the availability of commodities at facilities. Please refer to Appendix B for a full breakdown of the availability data across sectors. 3.1 Overall Availability of SRHC This research showed that mean availability of SRHC in Kenya was 46%. Availability in the public sector was highest at 51%, while availability in the private and mission sectors was comparable to each other (44% and 42%, respectively). Differences between urban and rural areas within the same sector were small. For instance, availability in urban public facilities was 53% and in rural public facilities 50%. Table 2 shows the mean availability of SHRC across sectors and locations. Eleven of the 53 SRHC researched were available at less than a quarter of all health facilities, while 24 of the 53 were available at more than half of all health facilities. Figure 1 illustrates the overall mean availability of each SRHC. Percentage Availability Overall Urban Rural Public Private Mission Total Table 2: Mean availability of SRHC by sector and location. 3.2 Availability of SRHC by Sector A closer examination of the availability of selected SRHC across the public, private and mission sectors, and urban and rural locations follows below. Figure 2 is an overview of the availability of the commodities across the sectors, while Figures 3, 4 and 5 illustrate the availability of SRHC in urban and rural areas in the public, private and mission sectors, respectively. Please refer to Appendix B for a full breakdown of availability data across sectors. Contraceptives Ethinylestradiol + levonorgestrel tablets, commonly known as the birth control pill, were available in 59% of urban public facilities and 55% of rural public facilities. In the private sector, availability was similar to the public sector, while in the mission sector availability was lower: 26% and 13% of urban and rural facilities, respectively, had the tablets. Levonorgestrel tablets (30 mcg), used as an emergency contraceptive after birth 7

8 Ethinyl/levonorgestrel Ethinyl/norethisterone Levonorgestrel 30mcg Levonorgestrel 70mcg Medroxyprogesterone acetate Norethisterone enanthate Male condoms Female condoms Intrauterine contraceptive devices Levonorgestrel implant Etonogestrel implant Diaphragm Oxytocin injection Misoprostol Metronidazole Methyldopa Magnesium sulfate Magnesium sulfate Calcium gluconate Clotrimazole pessary Clotrimazole cream Gentamicin injection Ampicillin Procaine benzylpenicillin Benzathine benzylpenicillin G Amoxicillin Dexamethasone Ferrous salt tablet Folic acid tablet Ferrous:Folic tablet 60/400 Ferrous:Folic tablet 150/500 Zinc 10mg/5ml syrup Zinc 20mg tablet Zinc:Oral rehydration salts co-pack Oral rehydration salts 200ml Oral rehydration salts 500ml Oral rehydration salts 1L Vasectomy kits Tuboligation kits Antiseptic Manual vacuum aspiration kits Speculum Cervical dilators Incubator Monitor Ultra sound scan Ventilator Fetal scope Resuscitator Bag and mask size 0 Suction device Mama Kit Training manikin 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 1: Mean percentage availability of SRHC. 8

9 control failure or unprotected intercourse, were inconsistently available. For instance, in the public sector, the 30 mcg tablets were available in 64% of facilities and the 750 mcg tablets were available in 7%. Medroxyprogesterone acetate, an injectable birth control, was highly availability in the public sector (95%), moderately availability in the private sector (76%), and of low availability in the mission sector (24%). Male condoms had a similar pattern as injectable birth control with regards to availability: High availability in the public sector (91%), moderate availability in the private sector (76%), and low availability in the mission sector (26%). 50% of public sector facilities had female condoms available, while availability in the private and mission sectors was very low (12%). Pregnancy and Childbirth Availability of pregnancy supplements averaged around 50%. Highest availability of a supplement was found for folic acid tablets, which were found in 73% of rural mission facilities. In the remaining the sectors, availability ranged from 40% in rural private facilities to 68% in urban private and mission facilities. Ferrous salt tablets and 20mg zinc tablets had comparable availability to folic acid tablets: Ferrous salt tablets were available in 41% to 58% of facilities, and zinc tablets in 45% to 60% of facilities. Oral rehydration (ORS) sachets of 500 ml were available in 34% of the public sector, 48% of the private sector, and 74% of the mission sector. Other supplement formulations were available to a lesser extent. Gentamicin, used to treat pneumonia and maternal and neonatal sepsis, had highest availability of SRHC commodities used for antenatal and post-natal care: Availability in the sectors ranged from 79% in private sector facilities to 82% in mission sector facilities. Oxytocin, used to induce labour and for the prevention and treatment of post-partum haemorrhage, also had similar availability. It was available in 82% of public and mission sector facilities, and in 71% of private sector facilities. Misoprostol, another medicine used to induce labour, was available in only 36% of public facilities, and in 57% and 59% of private and mission sector facilities, respectively. Magnesium sulphate (500 mg in 10 ml), used in the treatment of pre-term labour and pre-eclampsia, was available in 73% of public sector facilities and in 65% of mission sector facilities. In the private sector, availability was lower (40%). Availability of dexamethasone, used in the management of pre-term labour for improving foetal lung maturity, was similar in the public and mission sectors (64% and 62%, respectively), but was again lower in the private sector (50%). Sexually Transmitted Infections Benzathine benzylpenicillin, used in the treatment of syphilis, had an availability of 68% in the public sector, 45% in the private sector, and 76% in the mission sector. Clotrimazole pessary and cream, used to treat yeast infections, had similar availability patterns to each other. For instance, in the public sector, clotrimazole pessary and cream were available in 77% and 80% of facilities, respectively, and 69% and 64%, respectively, in the private sector. Availability of metronidazole, used for treating vaginal infections, ranged from 67% availability in rural private facilities to 89% in rural mission facilities. 9

10 Medical Devices and Procedures It was not common to find vasectomy and tubal ligation kits at facilities. Vasectomy kits ranged from 0% availability in rural mission facilities to 15% in rural private facilities. Availability of tubal ligation kits was similar, ranging from 0% in rural mission facilities to 23% in urban private facilities. Speculums had a relatively high availability, as 82% of public facilities, 88% of private facilities, and 91% of mission facilities had a speculum available. Ultrasound scans were available to a lesser extent, and had lower availability in rural facilities than urban facilities. For instance, urban public facility availability was 59% while rural public facility availability was 36%. Incubators were available in 68% of public facilities, 50% of private facilities, and 59% of mission facilities. Antiseptic, important in preventing infections as a consequence of surgical procedures, had a low availability across all sectors, ranging from 23% in the public sector to 33% in the private sector. Suction devices, also important during surgery, were available in more facilities; however, differences between urban and rural areas were found in the public and private sectors. For instance, in the public sector, suction devices were available in 91% of urban facilities and in 77% of rural facilities. 10

11 Ethinyl/levonorgestrel Ethinyl/norethisterone Levonorgestrel 30mcg Levonorgestrel 70mcg Medroxyprogesterone acetate Norethisterone enanthate Male condoms Female condoms Intrauterine contraceptive devices Levonorgestrel implant Etonogestrel implant Diaphragm Oxytocin injection Misoprostol Metronidazole Methyldopa Magnesium sulfate Magnesium sulfate Calcium gluconate Clotrimazole pessary Clotrimazole cream Gentamicin injection Ampicillin Procaine benzylpenicillin Benzathine benzylpenicillin G Amoxicillin Dexamethasone Ferrous salt tablet Folic acid tablet Ferrous:Folic tablet 60/400 Ferrous:Folic tablet 150/500 Zinc 10mg/5ml syrup Zinc 20mg tablet Zinc:Oral rehydration salts co-pack Oral rehydration salts 200ml Oral rehydration salts 500ml Oral rehydration salts 1L Vasectomy kits Tuboligation kits Antiseptic Manual vacuum aspiration kits Speculum Cervical dilators Incubator Monitor Ultra sound scan Ventilator Fetal scope Resuscitator Bag and mask size 0 Suction device Mama Kit Training manikin 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Public Private Mission Figure 2: Mean percentage availability of SRHC across public, private and mission facilities. 11

12 Ethinyl/levonorgestrel Ethinyl/norethisterone Levonorgestrel 30mcg Levonorgestrel 70mcg Medroxyprogesterone acetate Norethisterone enanthate Male condoms Female condoms Intrauterine contraceptive devices Levonorgestrel implant Etonogestrel implant Diaphragm Oxytocin injection Misoprostol Metronidazole Methyldopa Magnesium sulfate Magnesium sulfate Calcium gluconate Clotrimazole pessary Clotrimazole cream Gentamicin injection Ampicillin Procaine benzylpenicillin Benzathine benzylpenicillin G Amoxicillin Dexamethasone Ferrous salt tablet Folic acid tablet Ferrous:Folic tablet 60/400 Ferrous:Folic tablet 150/500 Zinc 10mg/5ml syrup Zinc 20mg tablet Zinc:Oral rehydration salts co-pack Oral rehydration salts 200ml Oral rehydration salts 500ml Oral rehydration salts 1L Vasectomy kits Tuboligation kits Antiseptic Manual vacuum aspiration kits Speculum Cervical dilators Incubator Monitor Ultra sound scan Ventilator Fetal scope Resuscitator Bag and mask size 0 Suction device Mama Kit Training manikin 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Public Urban Public Rural Figure 3: Mean percentage availability of SRHC in public sector facilities in urban and rural locations. 12

13 Ethinyl/levonorgestrel Ethinyl/norethisterone Levonorgestrel 30mcg Levonorgestrel 70mcg Medroxyprogesterone acetate Norethisterone enanthate Male condoms Female condoms Intrauterine contraceptive devices Levonorgestrel implant Etonogestrel implant Diaphragm Oxytocin injection Misoprostol Metronidazole Methyldopa Magnesium sulfate Magnesium sulfate Calcium gluconate Clotrimazole pessary Clotrimazole cream Gentamicin injection Ampicillin Procaine benzylpenicillin Benzathine benzylpenicillin G Amoxicillin Dexamethasone Ferrous salt tablet Folic acid tablet Ferrous:Folic tablet 60/400 Ferrous:Folic tablet 150/500 Zinc 10mg/5ml syrup Zinc 20mg tablet Zinc:Oral rehydration salts co-pack Oral rehydration salts 200ml Oral rehydration salts 500ml Oral rehydration salts 1L Vasectomy kits Tuboligation kits Antiseptic Manual vacuum aspiration kits Speculum Cervical dilators Incubator Monitor Ultra sound scan Ventilator Fetal scope Resuscitator Bag and mask size 0 Suction device Mama Kit Training manikin 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Private Urban Private Rural Figure 4: Mean percentage availability of SRHC in private sector facilities in urban and rural locations. 13

14 Ethinyl/levonorgestrel Ethinyl/norethisterone Levonorgestrel 30mcg Levonorgestrel 70mcg Medroxyprogesterone acetate Norethisterone enanthate Male condoms Female condoms Intrauterine contraceptive devices Levonorgestrel implant Etonogestrel implant Diaphragm Oxytocin injection Misoprostol Metronidazole Methyldopa Magnesium sulfate Magnesium sulfate Calcium gluconate Clotrimazole pessary Clotrimazole cream Gentamicin injection Ampicillin Procaine benzylpenicillin Benzathine benzylpenicillin G Amoxicillin Dexamethasone Ferrous salt tablet Folic acid tablet Ferrous:Folic tablet 60/400 Ferrous:Folic tablet 150/500 Zinc 10mg/5ml syrup Zinc 20mg tablet Zinc:Oral rehydration salts co-pack Oral rehydration salts 200ml Oral rehydration salts 500ml Oral rehydration salts 1L Vasectomy kits Tuboligation kits Antiseptic Manual vacuum aspiration kits Speculum Cervical dilators Incubator Monitor Ultra sound scan Ventilator Fetal scope Resuscitator Bag and mask size 0 Suction device Mama Kit Training manikin 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Mission Urban Mission Rural Figure 5: Mean percentage availability of SRHC in mission sector facilities in urban and rural locations. 14

15 3.3 Stock-out Days Stock-out information was only recorded by data collectors when stock information could be seen via a stock card or stock-taking database. As a result, in cases where stock information was not recorded, or anecdotal evidence was presented, the stock-out days could not be recorded. Please refer to Appendix C for a full breakdown of the stock-out data across sectors. Many facilities did not have stock-out cards during data collection. Stock-outs occurred in 2% of public facilities, 0.6% of private facilities, and 5% of mission facilities (see Table 3). The number of stock-out days differed per sector: There were six in the public sector, two in the private sector and 10 in the mission sector. Percentage of Facilities Reporting Stock-outs Public 2 6 Private Mission 5 10 Average Number of Stock-out Days per Month Table 3: Percentage of facilities reporting stock-outs in the six months prior to survey and the average number of stock-outs recorded per facility. Stock-outs for specific SRHC in the public sector ranged from 0% to 9%, of which ethinylestradiol + levonorgestrel tablets were the most stocked-out commodity, followed by levonorgestrel implants and methyldopa (7%). In the private sector, 10 of the commodities were stocked-out at 2.4% of the facilities, while other SRHC did not experience stock-outs. In the mission sector, stock-outs ranged from 0% to 18%, of which magnesium sulphate 500 mg in 2 ml (18%) was the most stocked-out, followed by ampicillin and ORS sachets of 200 ml and 1L (15%). Three other SRHC were stocked-out at 12% of facilities. Figure 6 shows the percentage of stock-outs for each SRHC. In the public sector, four of the 37 SRHC for which stock-out data was collected were unavailable for more than 20 days per month, of which two commodities were stocked-out the entire month. In the private sector, one commodity was unavailable the entire month, and another was unavailable for more than 20 days. The mission sector had nine commodities unavailable for the entire month, and another two unavailable for 20 days or more per month. Figure 7 illustrates the number of stock-out days per sector and commodity. 15

16 Ethinyl/levonorgestrel Ethinyl/norethisterone Levonorgestrel 30mcg Levonorgestrel 70mcg Medroxyprogesterone acetate Norethisterone enanthate Male condoms Female condoms Intrauterine contraceptive Levonorgestrel implant Etonogestrel implant Diaphragm Oxytocin injection Misoprostol Metronidazole Methyldopa Magnesium sulfate Magnesium sulfate Calcium gluconate Clotrimazole pessary Clotrimazole cream Gentamicin injection Ampicillin Procaine benzylpenicillin Benzathine benzylpenicillin G Amoxicillin Dexamethasone Ferrous salt tablet Folic acid tablet Ferrous:Folic tablet 60/400 Ferrous:Folic tablet 150/500 Zinc 10mg/5ml syrup Zinc 20mg tablet Zinc:Oral rehydration salts Oral rehydration salts 200ml Oral rehydration salts 500ml Oral rehydration salts 1L Number of Days Ethinyl/levonorgestrel Ethinyl/norethisterone Levonorgestrel 30mcg Levonorgestrel 70mcg Medroxyprogesterone Norethisterone enanthate Male condoms Female condoms Intrauterine Levonorgestrel implant Etonogestrel implant Diaphragm Oxytocin injection Misoprostol Metronidazole Methyldopa Magnesium sulfate Magnesium sulfate Calcium gluconate Clotrimazole pessary Clotrimazole cream Gentamicin injection Ampicillin Procaine benzylpenicillin Benzathine Amoxicillin Dexamethasone Ferrous salt tablet Folic acid tablet Ferrous:Folic tablet 60/400 Ferrous:Folic tablet Zinc 10mg/5ml syrup Zinc 20mg tablet Zinc:Oral rehydration Oral rehydration salts Oral rehydration salts Oral rehydration salts 1L Percentage of Facilities Not Stocked Public Private Mission Figure 6: Percentage of facilities reporting stock-outs for SRHC in the six months prior to survey PUBLIC PRIVATE MISSION Figure 7: Average number of reported stock-out days per month for SRHC in public, private and mission sectors. 16

17 3.4 SRHC Prices in Public, Private and Mission Sectors The following sections contain data analysed from Section B of the methodology, SRHC: Measuring Prices, Availability and Affordability. This section measures the pricing of commodities at facilities. Affordability of SRHC is based on the salary of the lowest-paid government worker in Kenya in 2017, the year of data collection. In Kenya, this is 411 Kenyan Shillings (KES) per day. SRHC not included in the analysis below are those which are not typically sold in facilities, such as equipment and devices (e.g., incubators and monitors). Prices displayed are for individual units of a commodity; a unit is the single most effective amount of a commodity that can be used (e.g., one tablet, a strip of 28 contraceptive tablets, 1ml or 1 vial). Please refer to Appendix D for a full breakdown of the price and affordability data across sectors. Where the commodity was not available across all sectors or locations, it has been removed from the figure. Patients had to pay for SRHC in all sectors. The mean prices of SRHC in the public sector ranged from 0 KES (10 commodities) to 63 KES (intrauterine contraceptive devices). In the private sector, mean prices ranged from 0 KES (3 commodities) to 667 KES (levonorgestrel implant), while the mean prices in the mission sector ranged from 0 KES (3 commodities) to 540 KES (levonorgestrel implant). Commodity Prices in Kenyan Shilling (KES) Public Sector Private Sector Mission Sector Mean Unit Price Min Unit Price Max Unit Price Mean Unit Price Min Unit Price Max Unit Price Mean Unit Price Min Unit Price Ethinyl/levonorgestrel Ethinyl/norethisterone N/A N/A N/A Levonorgestrel 30mcg Levonorgestrel 70mcg Medroxyprogesterone acetate Norethisterone enanthate N/A N/A N/A N/A N/A N/A Male condoms Female condoms Max Unit Price Intrauterine contraceptive devices Levonorgestrel implant Etonogestrel implant Diaphragm N/A N/A N/A N/A N/A N/A Oxytocin injection Misoprostol Metronidazole Methyldopa Magnesium sulfate Magnesium sulfate Calcium gluconate Clotrimazole pessary Clotrimazole cream Gentamicin injection Ampicillin

18 Ethinyl/levonorgestrel Ethinyl/norethisterone Levonorgestrel 30mcg Levonorgestrel 70mcg Medroxyprogesterone acetate Norethisterone enanthate Male condoms Female condoms Intrauterine contraceptive devices Levonorgestrel implant Etonogestrel implant Oxytocin injection Misoprostol Metronidazole Methyldopa Magnesium sulfate Magnesium sulfate Calcium gluconate Clotrimazole pessary Clotrimazole cream Gentamicin injection Ampicillin Procaine benzylpenicillin Benzathine benzylpenicillin G Amoxicillin Dexamethasone Ferrous salt tablet Folic acid tablet Ferrous:Folic tablet 60/400 Ferrous:Folic tablet 150/500 Zinc 10mg/5ml syrup Zinc 20mg tablet Zinc:Oral rehydration salts co-pack Oral rehydration salts 500ml Oral rehydration salts 1L Days of Wages Procaine benzylpenicillin Benzathine benzylpenicillin G Amoxicillin Dexamethasone Ferrous salt tablet Folic acid tablet Ferrous:Folic tablet 60/ Ferrous:Folic tablet 150/ N/A N/A N/A Zinc 10mg/5ml syrup Zinc 20mg tablet Zinc:Oral rehydration salts co-pack Oral rehydration salts 200ml N/A N/A N/A Oral rehydration salts 500ml Oral rehydration salts 1L N/A N/A N/A Note: N/A denotes SRHC was unavailable and, therefore, no price or affordability information can be calculated. Table 4: SRHC mean, minimum and maximum unit prices in public, private and mission sector facilities. 3.5 SRHC Affordability in Public, Private and Mission Sectors Using the wages of a lowest-paid government worker in Kenya in 2017, affordability of SRHC in the public sector ranged from optimal (0 days of wages) to 0.15 days of wages. In the private sector, SRHC were more expensive and affordability therefore differed. The levonorgestrel implant cost a lowest-paid government worker 1.62 days of wages, and two other SRHC cost this worker more than one day of wages, as well. In the mission sector, affordability ranged from optimal (0 days of wages) to 1.31 days of wages. Appendix D and Figure 8 show the affordability of SRHC by sector. 2,0 1,5 1,0 0,5 0,0 Public Private Mission Figure 8: Affordability of SRHC in public, private and mission sectors. 18

19 3.6 Stakeholder Interviews The following sections contain data analysed from Section B of the methodology, SRHC: Measuring Prices, Availability and Affordability. This section investigates access to SRHC, in general, and at particular facilities from the perspective of the interviewed health provider. The respondents remained the same as those providing assistance in Part A of the survey. The response rate for the survey was 89 percent; 15 people declined to answer the qualitative component of the survey. Please refer to Appendix E for a full breakdown of the data across the sectors. Key Challenges to SRHC Access Respondents were asked what they thought were the key challenges to SRHC access. They were given six options and the opportunity to add further suggestions. Respondents could choose as many options as they thought applicable. The options were: a. There is no demand for medicines/commodities. b. Requested medicines and commodities are not supplied. c. Logistical issues for supply of medicines/commodities. d. Training of staff. e. Cost of medicines to patients. f. Frequent stock outs. g. Other (specify): Training of staff (30%) and logistical issues for supply (26%) were the most commonly mentioned key challenges to SRHC access. These challenges were followed by costs to patients and the fact that requested commodities were not supplied (22%), as well as frequent stock-outs (21%). (See Figure 9.) 35% 30% 25% 20% 15% 10% 5% 0% No demand for commodities Requested commodities are not supplied Logistical issues for supply Training of staff Cost to patients Frequent stock outs Figure 9: Key challenges to SRHC access. When the key challenges were ordered according to sector, it became clear that there were some differences. In the public sector, the biggest challenge to SRHC access, mentioned by 37% of respondents, was the logistical issues for supply, which was closely followed by the fact that requested commodities were not supplied (35%). Training of staff was 19

20 mentioned to be a problem by 30% of respondents in the public sector. In the private sector, the training of staff was mentioned by most respondents to be a key challenge to access to SRHC (43%). Frequent stock-outs (31%), costs to patients (29%) and logistical issues for supply (29%) were also mentioned by many. In the mission sector, costs to patients was the key challenge to access to SRHC according to respondents. Figure 10 is an overview of the challenges by sector. 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% No demand for commodities Requested commodities are not supplied Logistical issues for supply Training of staff Cost to patients Frequent stock outs Public Private Mission Figure 10: Key challenges to SRHC access in public, private and mission sectors. Improving Access to SRHC Respondents were asked what they thought could be done to improve access to SRHC in Kenya. Where possible, they were also asked to list their top three priorities. Responses were similar across the sectors, but the percentage of respondents who thought it a viable option to improve access differed per sector (Figure 11). For instance, in the public and private sectors 60% and 57%, respectively, believed that improving the supply chain could improve access to SRHC. In the mission sector, 21% of respondents shared this belief. Improvements to the supply chain included accurate ordering of SRHC, efficient and accurate delivery, and a move to a pull system, rather than a push system, of SRHC stock ordering. Continued education or training for health workers was also often mentioned by respondents in all sectors: 23% of public sector respondents, 36% of private sector respondents, and 26% of mission sector respondents believed this recommendation was a way to improve SRHC access. In the private sector, the second most commonly mentioned recommendation was to educate clients on SRH and services (40%), which was put forward by 12% of public sector and 16% of mission sector respondents. Interestingly, improving the infrastructure for access was mentioned by 23% of public sector respondents, but was not a recommendation made often by respondents from the other sectors. 20

21 Improve supply chain Sensitisation/training of staff Work with church to address availability Increase staffing Use of mobile clinics Lower costs for clients Improve professionalism at outlets Ensure all SRHC are available Integration of services Educate communities in schools/church/commu Encourage spouses to attend Special youth friendly services Improve supply chain Improve quality of service Integration of services Provide greater choice of SRHC More staff recruited Rational use of medicines Continued education/training for Increase outlets Reduce costs Discuss supply approach at mission facilities Educate clients on SRH and services Improve professionalism Improve infrastructure for access 70% 60% 50% 40% 30% 20% 10% 0% Public Private Mission Figure 11: Improving access to SRHC in public, private and mission sectors. Ensuring Access to SRH Services at Facilities Respondents were also asked what could be done to ensure access to SRH services at the facility in which they worked. In all sectors, two recommendations, the supply chain and educating communities on SRH services and commodities, were most highly prioritised (Figure 12). In the public sector, 51% of respondents prioritised educating communities, while 49% said improving the supply chain was important. In the private sector, 50% of respondents recommended educating communities and improving the supply chain. Lowering costs for clients was recommended by 26% of respondents. In the mission sector, 37% recommended improving the supply chain, while 34% recommended education for communities. Interestingly, 21% of the respondents also recommended working with the church to address availability. In both the private (19%) and mission (21%) sectors, respondents also believed sensitisation or training of staff was a way to ensure access to SRH services at their facilities. 60% 50% 40% 30% 20% 10% 0% Public Private Mission Figure 12: Ensuring access to SRH services in public, private and mission sector facilities. 21

22 Fear of side effects Myths/Superstition/Religion Stigma from family members/community Low participation from males Pateint lack of knowledge Poverty/costs Poor professionlism from health workers Reluctance for Clients to Access SRHC Respondents were asked if they thought clients that visited their facility were often reluctant to visit for SRHC and SRH services. If respondents replied, Yes, they were then asked to provide their thoughts on the reasons for this reluctance and what they believed could be done to tackle this issue. Of the respondents, 56% believed that clients were reluctant to access SRHC (see Figure 13). When they were asked why clients were reluctant to access SRH services, answers differed to some extent among respondents from different sectors. In the public sector, the most commonly mentioned reasons for client reluctance to access SRHC were myths, superstition or religion (23%), stigma from family members and the community (19%), and patients lack of knowledge (19%). In the private sector, myths, superstition or religion was also the most commonly given reason for client reluctance (33%), followed by patients lack of knowledge (17%) and low participation from males (14%). The mission sector differed, as poverty and costs were mentioned by most respondents (16%), followed by myths, superstition or religion (13%). Figure 14 provides an overview of the responses. When respondents were asked about ways to decrease clients reluctance to access SRHC, 51% recommended improving client education for everyone, meaning for both men and women (see Figure 15). 60% 50% 40% 30% 20% 10% 0% Yes No Figure 13: Reluctance for clients to access SRHC. 35% 30% 25% 20% 15% 10% 5% 0% Public Private Mission Figure 14: Reasons for client reluctance in accessing SRHC in public, private and mission sector facilities. 22

23 60% 50% 40% 30% 20% 10% 0% Increased service availability Improve quality of services through training and outreach Improve stock available Involve partners in issues Expand client education for all Note: Involving partner in issues meant involving males in the SRH of their female partners to aid understanding. Figure 15: Possible improvements to overcome client reluctance to access SRHC at facilities. 23

24 4. Discussion This is the first roll-out of a planned yearly survey as part of Health Action International s SRHC research under the Health Systems Advocacy (HSA) Partnership. This research aims to create a clear picture of Kenya s current situation regarding access to SRHC, and to identify the best way to improve access to these commodities. This research showed that availability of SRHC is low in Kenya, as only 46% of the commodities were available in the facilities. Availability across the sectors was similar, with highest availability in the public sector (51%). Moreover, 20% of the commodities researched were available at only a quarter of the facilities, while an average of only 45% of commodities were available at more than half of the facilities. In general, availability of SRHC was inconsistent and ranged from commodities being available at only 3% to 87% of facilities. In both urban and rural mission sector facilities, none of the contraceptive commodities were available in more than 40% of facilities. Availability of contraceptives was generally highest in the public sector, lower in the private sector, and lowest in the mission sector. For instance, in the public sector, levenorgestrel tablets were available in 64% of facilities, while in the private and mission sectors, it was available in 40% and 21% of facilities, respectively. In Kenya, the most commonly used contraceptives are injectables and implants 3. Medroxyprogesterone acetate, an injectable contraceptive, was commonly available in the public sector (95%), moderately available in the private sector (76%), and scarcely available in the mission sector (24%). Implants were also more commonly available in the public sector (around 80%), and had the worst availability in the mission sector (around 20%). In Kenya, 18.5% of women still have unmet needs for family planning 4, and suboptimal availability of the contraceptives may contribute to this. Some antenatal and post-natal commodities, such as oxytocin and gentamicin, had relatively high availability across all sectors around 70% to 80% for both medicines. Other antenatal and post-natal commodities were often available in approximately 60% to 70% of public sector facilities, with the exception of misoprostol, which was available in only 36% of public facilities. Access to these commodities is important to ensure a healthy pregnancy and life for both the mother and the baby, and when they are not available, it can lead to serious morbidity and mortality. Since the maternal mortality rate is still high in Kenya (360 per 100,000 live births) 5, it is crucial to improve the availability of these commodities. The same is the case with medical devices and procedures available at facilities; important devices and procedures that had a lower availability, such as ultrasound scans, incubators, and antiseptic, have a significant impact on the health outcomes of mothers and babies as it affects the quality of treatment offered to the clients. 3 United Nations, Department of Economic and Social Affairs, Population Division. Trends in Contraceptive Use Worldwide (Geneva: United Nations, 2015), p United Nations, Department of Economic and Social Affairs, Population Division. p United Nations Children s Fund (UNICEF). The State of the World s Children 2016: a fair chance for every child. (New York: UNICEF, 2016), p

25 Commodities to treat sexually transmitted infections (STI) were generally available in more than 60% of facilities, even going up to 95% availability for clotrimazole pessary in urban mission sector facilities. The only exception to this general availability was benzathine benzylpenicillin in the private sector (45% availability). Given that in 2012, alone, there was an estimated 62 million new cases of curable STI in the sub-saharan Africa region 6, the relatively high availability of commodities to treat STI is a good and necessary step in ensuring the treatment of a large proportion of those affected by STI. However, improvements in availability are still necessary. Stock-outs occurred least in the private sector and most in the mission sector. Across sectors, the number of stock-out days differed. The average number of stock-out days in the private sector was lowest (two days), followed by the public sector (six days) and the mission sector (10 days). It is important to note that when stock-outs occurred, almost 11% of the commodities in the public sector were stocked-out for more than 20 days a month, which increased to 30% of commodities in the mission sector. Since availability of SRHC is already sub-optimal, stock-outs can have a more significant impact on access to SRHC than these numbers present. Frequent stock-outs were also mentioned to be a major challenge by 21% of the respondents. It is important to note that stock cards were not available at a number of facilities, which may have led to an underestimation of stock-outs. In general, patients had to pay for SRHC in all sectors. In the public sector, the most expensive SRHC cost a lowest-paid government worker 0.15 days of wages, and in the private and mission sector, 1.62 days and 1.31 days, respectively. Although it may seem that affordability is therefore not a problem, costs to patients were mentioned to be a major challenge in access to SRHC, especially by respondents from the private (29%) and mission (26%) sectors. This is not surprising, given that Kenya s lowest-paid government worker earns the equivalence of USD a day, while the last reported poverty rate of people living below the international poverty line of USD 1.90 was 33.6% 8. Stock-outs and costs to patients were not only thought to be key challenges affecting access to SRHC; other challenges included the lack of staff training on SRH, logistical issues for supply, and the fact that requested commodities are not supplied. To improve access to SRHC, the following recommendations are made: Improve the supply chain. o Efficient and accurate delivery. o Move to a pull system of SRHC stock ordering. 6 Newman L, Rowley J, Vander Hoorn S, Wijesooriya NS, Unemo M, Low N, et al. Global Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global Reporting. PLoS ONE, 10, no. 12 (2015), e Based on currency conversion of KES to USD for the value of KES in USD on 13 August, 2017 via 8 The World Bank. Poverty & Equality Data Portal: Kenya. Accessed 23 November, 2017: 25

26 Provide (continued) training for staff. Provide client and community education on SRH and services. Recommendations to improve access to SRHC at their own facilities are of the same nature as the general recommendations. Exceptions to this are the recommendations to lower the costs for patients in the private sector and, in the mission sector, to work with the church to address availability. To decrease reluctance of clients to access SRHC, which was thought to be a substantial problem, expanding client education, for both men and women, was recommended. Conclusion The lack of availability of commodities, the stock-outs, the unaffordability of SRHC and challenges at community and facility levels all contribute to the difficulties people experience in accessing SRH services, as well as to the almost 20% of women that still have unmet family planning needs. Improvements in accessing SRHC in Kenya are therefore needed to achieve the Sustainable Development Goal of universal access to sexual and reproductive healthcare services. This survey showed that community education might have a considerable impact on health-seeking behaviour of clients. Improving knowledge in the community about SRH will tackle many of the reasons given as to why 56% of clients are reluctant to access SRH services. For instance, comprehensive education on SRH will improve the general knowledge about SRH, which will in turn target the myths, superstitions and religious factors negatively influencing SRH services use. In addition, client and community education can lead to a reduction in stigmatisation of SRH service users by family and the community. Related to community education is staff sensitisation. Staff sensitisation and continued education is needed to ensure clients feel comfortable in accessing SRH services at facilities. To achieve this, it is important that staff is sufficiently knowledgeable about SRH and available SRH services so they can offer quality care, are professional in their approach, and ensure that no stigmatisation occurs within the facility. Improving client and staff education is not enough, however. If the commodities are not available they cannot be accessed. Therefore, another important area of focus to improve access to SRH services is the pharmacy chain. A sub-optimal pharmacy chain leads to problems with availability and stock-outs of the commodities. To improve the pharmacy chain, SRHC should be accurately ordered, the delivery should be efficient, accurate and timely, and a closer look should be taken to determine if a pull system would work better than the push system, which is currently in use, in Kenya. Finally, costs are also an important access-limiting factor in the private and mission sectors for which solutions should be developed. 26

27 5. Appendices 5.1 Appendix A SRHC Surveyed Commodity Ethinylestradiol + levonorgestrel (tablet, 30 mcg mcg) Ethinylestradiol + norethisterone (tablet, 35 mcg mg) Levonorgestrel (tablet, 30 mcg) Levonorgestrel (tablet, 750 mcg) Medroxyprogesterone acetate (150mg in 1 ml vial) Norethisterone enanthate (200mg/ml in 1 ml vial) Male condoms Female condoms Intrauterine contraceptive devices Implants: Levonorgestrel Implants: Etonogestrel Diaphragm Oxytocin injection (10IU, 1ml) Misoprostol (200 mcg tablet) Metronidazole (tablet, 200mg) Methyldopa (tablet, 250mg) Magnesium sulfate (500mg in 2ml) Magnesium sulfate (500mg in 10ml) Calcium gluconate (100mg in 10ml ampoule) Clotrimazole (pessary 500mg) Clotrimazole (cream 1% in 15g tube) Gentamicin injection (40mg/ml in 2ml) Ampicillin (500mg powder for injection) Procaine benzylpenicillin, fort (powder for injection 4MU) Benzathine benzylpenicillin G (2.4MU in 10ml) Amoxicillin (125mg/250mg) Dexamethasone (4mg/ml) Ferrous salt tablet (200mg) Folic acid tablet (tablet 5mg) Ferrous salt and folic acid (tablet 60mg iron + 400mcg folic acid) Ferrous salt and folic acid (tablet 150mg iron + 500mcg folic acid) Zinc (10mg in 5ml syrup) Zinc (20mg tablet) Zinc oral rehydration salts co-pack (10mg tablet/1l) Oral rehydration salts (sachets of 200ml) Oral rehydration salts (sachets of 500ml) Oral rehydration salts (sachets of 1L) Vasectomy kits Tuboligation kits Antiseptic (chlorhexidine/alcohol) Manual vacuum aspiration kits Speculum Cervical dilators Incubator Monitor Ultrasound scan Ventilator Fetal scope Resuscitator Bag and mask (size 0) Suction device Mama kit Training manikin for infant resuscitation Table 5: Full list of SRHC surveyed. 27

28 5.2 Appendix B SRHC Availability Percentage Mean Availability (%) Public Private Mission Commodity Urban Rural Urban Rural Urban Rural Ethinylestradiol + levonorgestrel (tablet, 30 mcg mcg) 59% 55% 59% 75% 26% 13% Ethinylestradiol + norethisterone tablet (35 mcg + 9% 5% 5% 10% 0% 0% 1.0 mg) Levonorgestrel tablet (30 mcg) 64% 64% 36% 45% 26% 13% Levonorgestrel tablet (750 mcg) 5% 9% 27% 30% 5% 0% Medroxyprogesterone acetate (150mg in 1 ml vial) 95% 95% 68% 85% 26% 20% Norethisterone enanthate (200mg/ml in 1 ml vial) 0% 0% 14% 5% 0% 0% Male condoms 95% 86% 73% 80% 37% 13% Female condoms 45% 55% 14% 10% 16% 7% Intrauterine contraceptive devices 73% 73% 50% 60% 16% 13% Implants: Levonorgestrel 82% 82% 59% 90% 26% 13% Implants: Etonogestrel 82% 86% 55% 85% 26% 20% Diaphragm 0% 0% 0% 5% 0% 0% Oxytocin injection (10IU, 1ml) 82% 82% 68% 75% 89% 73% Misoprostol (200 mcg tablet) 45% 27% 55% 60% 68% 47% Metronidazole tablet (200mg) 82% 82% 77% 80% 89% 67% Methyldopa tablet (250mg) 59% 32% 77% 75% 68% 80% Magnesium sulfate (500mg in 2ml) 5% 9% 9% 0% 11% 7% Magnesium sulfate (500mg in 10ml) 73% 73% 36% 45% 68% 60% Calcium gluconate (100mg in 10ml ampoule) 45% 36% 27% 30% 37% 40% Clotrimazole (pessary 500mg) 73% 82% 77% 60% 95% 87% Clotrimazole (cream 1% in 15g tube) 77% 82% 59% 70% 84% 80% Gentamicin injection (40mg/ml in 2ml) 73% 86% 68% 90% 84% 80% Ampicillin (500mg powder for injection) 18% 18% 9% 20% 11% 7% Procaine benzylpenicillin, fort (powder for injection 41% 36% 14% 50% 16% 20% 4MU) Benzathine benzylpenicillin G (2.4MU in 10ml) 68% 68% 41% 50% 68% 87% Amoxicillin (125mg/250mg) 68% 82% 68% 85% 89% 87% Dexamethasone (4mg/ml) 64% 64% 55% 45% 63% 60% Ferrous Salt (tablet 200mg) 55% 50% 41% 45% 58% 47% 28

29 Folic Acid (tablet, 5mg) 64% 55% 68% 40% 68% 73% Ferrous salt and folic acid (tablet 60mg iron + 64% 68% 32% 15% 37% 47% 400mcg folic acid) Ferrous salt and folic acid (tablet 150mg iron + 0% 5% 0% 0% 5% 7% 500mcg folic acid) Zinc (10mg in 5ml syrup) 0% 5% 23% 0% 5% 13% Zinc (20mg tablet) 45% 55% 59% 55% 47% 60% Zinc oral rehydration salt (co-pack 10mg/1ml) 59% 50% 14% 5% 26% 27% Oral rehydration salts (sachets of 200ml) 0% 5% 9% 0% 0% 0% Oral rehydration salts (sachets of 500ml) 32% 36% 50% 45% 79% 67% Oral rehydration salts (sachets of 1L) 5% 0% 9% 15% 0% 0% Vasectomy kits 9% 5% 9% 15% 5% 0% Tuboligation kits 14% 9% 23% 20% 11% 0% Antiseptic 23% 23% 36% 30% 37% 27% Manual vacuum aspiration kits 77% 64% 73% 75% 74% 67% Speculum 86% 77% 95% 80% 95% 87% Cervical dilators 73% 59% 73% 55% 63% 40% Incubator 77% 59% 59% 40% 58% 60% Monitor 64% 64% 45% 25% 58% 40% Ultrasound 59% 36% 45% 25% 68% 53% Ventilator 55% 36% 36% 30% 37% 20% Fetal scope 82% 77% 86% 85% 89% 87% Resuscitator 91% 77% 64% 50% 74% 53% Bag and mask 91% 73% 86% 60% 74% 73% Suction device 91% 77% 77% 60% 74% 73% Mama kit 45% 45% 36% 25% 16% 13% Training manikin 82% 50% 23% 30% 47% 20% Average 53% 50% 45% 44% 44% 39% Table 6: Percentage availability of SRHC across all sectors and locations. 29