Article Text

Download PDFPDF

Who pays and how much? A cross-sectional study of out-of-pocket payment for modern contraception in Kenya
  1. Emma Radovich1,
  2. Mardieh L Dennis1,
  3. Edwine Barasa2,
  4. Francesca L Cavallaro1,
  5. Kerry LM Wong1,
  6. Josephine Borghi3,
  7. Caroline A Lynch1,
  8. Mark Lyons-Amos1,
  9. Timothy Abuya4,
  10. Lenka Benova1,5
  1. 1 Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
  2. 2 Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
  3. 3 Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, London, UK
  4. 4 Population Council Kenya, Nairobi, Kenya
  5. 5 Department of Public Health, Instituut voor Tropische Geneeskunde, Antwerpen, Belgium
  1. Correspondence to Emma Radovich; emma.radovich{at}


Objectives Out-of-pocket (OOP) payment for modern contraception is an understudied component of healthcare financing in countries like Kenya, where wealth gradients in met need have prompted efforts to expand access to free contraception. This study aims to examine whether, among public sector providers, the poor are more likely to receive free contraception and to compare how OOP payment for injectables and implants—two popular methods—differs by public/private provider type and user’s sociodemographic characteristics.

Design, setting and participants Secondary analyses of nationally representative, cross-sectional household data from the 2014 Kenya Demographic and Health Survey. Respondents were women of reproductive age (15–49 years). The sample comprised 5717 current modern contraception users, including 2691 injectable and 1073 implant users with non-missing expenditure values.

Main outcome Respondent’s self-reported source and payment to obtain their current modern contraceptive method.

Methods We used multivariable logistic regression to examine predictors of free public sector contraception and compared average expenditure for injectable and implant. Quintile ratios examined progressivity of non-zero expenditure by wealth.

Results Half of public sector users reported free contraception; this varied considerably by method and region. Users of implants, condoms, pills and intrauterine devices were all more likely to report receiving their method for free (p<0.001) compared with injectable users. The poorest were as likely to pay for contraception as the wealthiest users at public providers (OR: 1.10, 95% CI: 0.64 to 1.91). Across all providers, among users with non-zero expenditure, injectable and implant users reported a mean OOP payment of Kenyan shillings (KES) 80 (US$0.91), 95% CI: KES 78 to 82 and KES 378 (US$4.31), 95% CI: KES 327 to 429, respectively. In the public sector, expenditure was pro-poor for injectable users yet weakly pro-rich for implant users.

Conclusions More attention is needed to targeting subsidies to the poorest and ensuring government facilities are equipped to cope with lost user fee revenue.

  • Kenya
  • family planning
  • user fees
  • demographic & health survey
  • private sector
  • government provision

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Patient consent for publication Not required.

  • Contributors ER designed the research question, analysed data and prepared the manuscript. LB, MLD, CL and JB contributed to the design of the study. KLMW contributed to analysis of the data. LB, MD, FLC and EB assessed interpretation of findings and contributed to manuscript revisions. JB, TA, KLMW and ML-A reviewed and edited the manuscript. All authors read and approved the final manuscript.

  • Funding The research in this publication was supported by funding from MSD, through its MSD for Mothers programme. MSD for Mothers is an initiative of Merck & Co, Kenilworth, New Jersey, USA. EB is supported by a Wellcome Trust research training grant (#107527).

  • Disclaimer MSD had no role in the design, collection, analysis and interpretation of data, in writing of the manuscript or in the decision to submit the manuscript for publication. The content of this publication is solely the responsibility of the authors and does not represent the official views of MSD.

  • Competing interests None declared.

  • Ethics approval The DHS receive government permission and follow ethical practices including informed consent and assurance of confidentiality. The Research Ethics Committee of the London School of Hygiene and Tropical Medicine approved our secondary data analysis.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data that support the findings of this study are owned by the Demographic and Health Surveys (DHS) Program, operated by ICF International. Restrictions apply to the availability of these data, which were used under licence for the current study, and so are not publicly available. Data are available for free from the DHS Program website and available for researchers who apply for and meet the criteria for access. Legal access agreements do not allow the sharing of datasets to unregistered researchers.