This paper applies an access framework to explore access barriers to effective malaria treatment among the poorest populations in Kenya. Here, the results are discussed in more detail and compared to the wider literature on access to health care. Access to malaria treatment is clearly influenced by multiple factors occurring at both the supply and the demand level. A summary of the interrelated barriers to access identified in this paper is provided in Figure .
Overall, a positive finding was that most reported fevers were treated within the first 24 hours of symptoms onset. Like in many parts of sub-Saharan Africa, over 50% of reported fevers were treated using drugs bought in the informal sector, with only about 20% treated in the public sector, the main source of formal care in the study settings. In Kenya, Coartem, the first-line anti-malarial, is not sold in the informal sector, implying that a high proportion of fevers treated in this sector were not treated effectively. Moreover, evidence suggests that even fevers treated in the formal public sector in the recent past have hardly been treated using the recommended anti-malarials [3
], due to various reasons related to all access dimensions including drug shortages, patient's preferences and perceived high costs of drugs [25
]. Additional data on the types of medicines used to treat malaria in the era of ACT, and the level of adherence to drug regimes would be useful in measuring the country's progress towards the Abuja targets.
Affordability is a major barrier to malaria treatment and health care throughout sub-Saharan Africa. On the demand side, health care charges, seasonal incomes, transport costs and waiting time all interact to make affordability a major barrier for the poorest households. Ready cash to pay for treatment was hardly available and households often mobilized additional resources mainly through borrowing from their social networks. Lack of money contributed to poor drug adherence since health workers and drug shops were reported to readily issue incomplete dosages. It was also reported that people who lacked money to pay for treatment were given inappropriate drugs at government facilities because they were reportedly cheaper than the recommended anti-malarials. Poor prescribing practices and drug adherence has potential implications for drug resistance and acceptability of services. For example, drug effectiveness was one of the factors that patients attributed to the satisfaction or otherwise of health services. Incomplete doses and less effective drugs are likely to clear the symptoms in the short-term, with the possibility of a recurring episode. As shown by the findings, recurring illnesses that are treated with incomplete doses or ineffective drugs can erode the trust in the health system, and thus impacting negatively on acceptability of health services.
All public health facilities in Kenya charge user fees. In an attempt to make malaria treatment affordable, the Kenyan government provides free anti-malarials to all public health care facilities, which ideally should be dispensed free of charge to malaria patients. Malaria treatment is therefore, officially free to all Kenyans. In a further development, in 2004, registration fees for malaria patients in all primary health care facilities were eliminated. However, the findings presented in this paper and elsewhere suggest that health care charges remain a significant barrier to access and that the 'free treatment' policy is not fully implemented for various reasons including [45
]: (1) poor policy design, where patients are required to pay consultation fees before being seen by a health worker; (2) low revenue, especially in districts where malaria is the main illness. Exempting malaria patients from paying fees in malaria endemic districts impacts heavily on the amount of revenue collected; (3) the difficulties of identifying patients suffering from malaria since many illness conditions have symptoms similar to malaria and many primary health care facilities do not have laboratories and; (4) shortage of drugs supplied by the government meant that facilities had to raise additional money through charging fees in order to raise money to purchase drugs. The government should work closely with health workers, district health management teams and health facility committees to ensure that people do not pay for anti-malarials in the public health sector. Non-health related interventions that address insecurity and fragility of income sources can have a significant role in minimizing affordability barriers and improving effective treatment [54
Regarding acceptability of treatment, about half of the people that sought care from formal health services reported that they were satisfied with the quality of services. Availability and effectiveness of drugs were the main factors given for satisfaction with health services. However, many community members in the study setting appeared to have strong negative perceptions of health workers attitudes and their ability to provide good quality care. Health workers were often reported to be disrespectful to patients and their qualifications were sometimes questioned. Such perceptions may often relate to cultural beliefs, which affect provider-patient interaction, but also demonstrate the reluctance to accept new health workers following transfer of more familiar and trusted staff. The fact that the negative perceptions towards health workers' age, gender and qualifications were expressed mainly by elderly women implies that they may have considerable cultural concerns, firstly, in exposing their bodies for injection to providers who were predominantly young males, and secondly, in tolerating the language of providers, which they regard as disrespectful to their age and social status as married women. In districts where CHWs assisted health workers to provide services at the facility level, community members expressed concerns regarding their expertise, and they were reluctant to be attended by CHWs who were mainly from the same community and well known to them. These findings demonstrate the challenges of using CHWs to support health workers in resource constraints regions. Plans are under way in Kenya to roll out the community health strategy that heavily relies on resources at the lower level, including CHWs, to improve the health status of the population. The success of this strategy will to some extent depend on the degree of CHWs acceptability at the community level.
Although the impact of negative perceptions of access to effective malaria treatment is difficult to measure, treatment-seeking behaviour has been shown to be strongly influenced by social relationships. People draw heavily on their social networks for advice; advice that is shaped by perceptions and rumors about health workers, quality of care and the health system in general [55
]. Gilson notes that provider-patient relationships are influenced by patients' attitudes towards providers [58
]. For example, providers personally known to patients or of the same ethnic group or gender may be more trusted. However, providers may also introduce or reinforce negative patient perceptions through their own practices [58
]. Health system constraints, such as poor remuneration, high workload and staff shortages, also play an important role in influencing provider-patient relationships [51
Although the role of provider patient relationships in hindering or promoting access is well documented [59
], interventions to improve the situation are inadequately considered in policy design, particularly in low income countries. In high and middle income countries, mechanisms such as patients' rights charters exist to provide information to service users and improve on provider-patients relationships [62
]. Similar initiatives have been introduced in Kenya but the extent to which the needs of the poor and vulnerable populations are met has not been documented. Building trust in the public health system through improving quality of care, making providers more accountable to service users, and listening to community voices are essential to promoting acceptability. Such interventions require long-term planning but a potential starting point should be a clear commitment and willingness by policy makers to work towards promoting and revitalizing the public health system.
Supply side factors
On the supply side, the main barriers to access included facility opening hours, distance to health care facilities, poor road networks, drugs and staff shortages. About a third of individuals who sought care from public health facilities did not get drugs from the hospital pharmacy because they were out of stock. Over half of the people issued with prescriptions to buy medicines outside the hospital pharmacy did not buy them.
People were particularly concerned about the chronic drug shortages in public facilities, shortages that were mainly attributed to inappropriate use by health workers. Participants also reported that these shortages were more serious during the wet season when the number of malaria cases was high and health facilities could not cope with the increased demand in malaria treatment. Drug supplies were not adjusted to sustain the increased demand. Lack of drugs can impact on acceptability of health services. When people do not receive the appropriate drugs due to frequent stock out, they develop negative perceptions of health workers and have limited trust in the health system. Drug shortages also contribute to high costs of treatment, and thus impact on affordability. Drug shortages in public health facilities mean that people have to buy drugs from private chemists often at a higher price, despite already having incurred some charges - for example consultation and laboratory fees - at the facility. It is worth considering the organization of health care services to ensure that people only incur charges at the health services if drugs are available.
Shortage of first-line anti-malarials has been reported as a main problem in the Kenyan health system [11
] and elsewhere in SSA [3
]. A recent study conducted in Kenya revealed that [11
]: 26 percent of public health facilities studied did not have any of the four AL weight-specific packs in stocks and 75 percent had at least one weight specific pack out of stock; a large proportion did not have packs for the youngest ages (the most vulnerable group to malaria); and some facilities reported not having ACT for close to two months. It is not clear why public health facilities experience chronic drug shortages, but it is stipulated that the drug supply system in Kenya is very inefficient. Other reasons include seasonality of illness, failure to account for differences in district health needs when designing the drug kits and delayed supply [45
]. The Kenyan government is aware of the drug shortage problems in public health facilities and plans are under way to change the drug supply system from one where facilities receive standard drug kits, to a pull system where facilities order their drugs based on their need. The new approach has been piloted in some parts of the country, although there is no information on its effectiveness. It is important that the new drug supply system is evaluated to ensure that it contributes to improved drug supply in the public health care system.
Distance to health facilities and poor road networks was not only a barrier to the community seeking care, but they also influenced the presence of health workers at the health facility. The public health facilities discussed in this study are located in some of the remotest areas in the districts with no housing facilities for the health workers. Consequently, many of the health workers resided in neighbouring towns and they often used public means of transport on a daily basis, transport that was heavily unreliable, and hardly operated during the rainy season due to the poor road conditions. Few studies have documented the impact of physical infrastructure on health workers ability to provide good quality services. While it is difficult to confirm whether provider lateness was mainly due to poor road network and unreliable transport, the findings demonstrate the relationship between availability and acceptability. Community members attributed lateness of providers and few working hours to poor work ethics and limited interest in their work and rarely associated it with some of the constraints faced by health workers.
Primary health care facilities were the main sources of care in the study settings. These facilities only operated within certain hours and remained closed during the weekend. Beyond the official opening hours, there was no source of formal care in these settings. Geographical location of health care facilities has been reported as a barrier to malaria treatment in Kenya [40
], but few studies identify primary health care facilities opening hours as a barrier to effective treatment. The findings have shown that primary health care facilities remain closed during the weekends, and other periods when the sole health worker is not available due to official or personal commitments. Yet these facilities are the closest to the population and are the only formal sources of treatment for the poorest population. Policy makers should reconsider the operating hours of primary health care facilities in remote rural settings. Other interventions that can address the availability barriers include providing mobile clinics and outreach programmes. These interventions will, however, require that additional health workers are deployed to these facilities and that appropriate anti-malarials and other essential drugs are readily available.
Table summarizes the possible policy actions to addresses barriers to effective malaria treatment identified in this paper. These actions involve the three access dimensions and include both short-term and long-term interventions. Interventions relating to the broader health system are also identified.
Policy actions to address barriers of access to prompt and effective malaria treatment.
A limitation of this work is that the findings are based on comments and reports of samples of people living in four poor rural settings in Kenya. Although the aim was to understand barriers to access among the poorest population, the urban poor might face different barriers due to contextual differences related to better infrastructure and more health care facilities. Regarding formal treatment, people discussed public health facilities far more than private facilities. This is most likely because no private providers operated in close proximity to these low income settings. However, the fact that people did not discuss about treatment in the private formal sector suggests that this sector is beyond the reach of the poorest population.