Insurance coverage, healthcare use, and outpatient payment among adults with disability in Kenya before the SHA transition: a secondary analysis of KDHS 2022

Healthcare is a fundamental need, but for many, it remains a financial gamble. In many parts of the world, people with disabilities often require more medical attention than others, yet they frequently face greater barriers in paying for it. This creates a difficult gap where the need for care is highest, but the ability to access it is lowest. To understand how well a health system is working, researchers look at three specific things: whether people have insurance to cover their costs, whether they actually visit a doctor when they need to, and what happens at the moment they receive care—specifically, who pays the bill. In Kenya, a major shift was about to happen in the health system, replacing an older insurance fund with a new authority designed to change how care is funded. Before this new system began, researchers needed a clear picture of the landscape as it stood, particularly for adults with disabilities, to see if the system was already failing them or if it was working as intended.

A team of researchers turned to a massive national survey conducted in 2022, which captured the lives of tens of thousands of Kenyan adults just before the country's health insurance transition. They focused on a specific group within that survey: adults who reported having a disability. Using a standard set of questions designed to identify functional difficulties, the team identified that roughly seven out of every one hundred adults in the survey met the criteria for having a disability. The researchers then compared this group to adults without disabilities to see if there were differences in their access to health insurance, how often they went to the hospital or clinic, and how they paid for those visits. They carefully adjusted their analysis to account for factors like age, where people lived, their wealth, and their education, ensuring that any differences they found were truly linked to disability status and not just to poverty or location.

The study revealed a complex picture of access and payment. At first glance, it appeared that adults with disabilities were significantly more likely to lack health insurance than those without disabilities. However, when the researchers accounted for the fact that people with disabilities in this survey tended to have lower incomes and less education, the gap in insurance coverage disappeared. This suggests that the higher rate of being uninsured was not caused by the disability itself, but rather by the economic disadvantages that often accompany it. Despite this, the need for medical care was undeniably higher for the disability group. Adults with disabilities were far more likely to visit outpatient clinics and to be admitted to hospitals than their peers without disabilities, a pattern that remained strong even after adjusting for wealth, age, and location.

The story of how these visits were paid told an even more revealing story about the reality on the ground. Among adults with disabilities who went to a clinic, the vast majority reported that they had to make a payment at the time of their visit, regardless of whether they had insurance or not. Having insurance did not guarantee a free visit. In fact, for those who did pay, having insurance was associated with a lower probability that any part of the payment was made in cash. When the researchers looked closely at the records of who actually contributed to the bill, they found that among insured outpatient users with disability who reported paying and had a recorded payer split, only 15.1% had a recorded insurer contribution. Because the survey did not collect payer information when no payment was reported, the true proportion of insured visits where the insurer contributed could only be estimated to fall somewhere between twelve and thirty-three percent. This means that for the majority of insured visits where data was available, the insurer contribution was limited, with the financial burden often remaining with the patient.

These findings provide a crucial baseline, a snapshot of the health system just before a major change took place. They show that while adults with disabilities in Kenya were using healthcare services at much higher rates, they were still facing significant out-of-pocket costs. The data suggests that simply having insurance was not enough to remove the financial barrier at the point of care. As the country moves forward with its new health authority, these numbers serve as a reference point to measure whether the new system is successfully ensuring that those with the greatest need can access care without being forced to pay the full price themselves. The study confirms that disability is a strong predictor of higher healthcare use, but it also highlights that economic factors and the specific design of payment systems play an equally critical role in determining who gets treated and who pays.