Determinants of Primary Healthcare Services Access by National Health Insurance Fund Capitated Members in Uasin Gishu County, Kenya

Determinants of Primary Healthcare Services Access by National Health Insurance Fund Capitated Members in Uasin Gishu County, Kenya | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Determinants of Primary Healthcare Services Access by National Health Insurance Fund Capitated Members in Uasin Gishu County, Kenya Barbara Were, Eunice Mwangi, Lillian Muiruri This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3949354/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Sep, 2024 Read the published version in BMC Health Services Research → Version 1 posted 4 You are reading this latest preprint version Abstract Purpose The study identifies provision of primary healthcare services using the capitated health model as a prerequisite for promoting positive healthcare outcomes for a country’s population. However, capitated members have continued to face challenges in accessing primary healthcare services despite enrolment in the National Health Insurance Fund (NHIF). This study sought to determine if variables such as patient knowledge of the NHIF benefit package, NHIF Premium Payment processes, selecting NHIF capitated health facilities, and NHIF Communication to citizens’ influences access to primary healthcare services. Method A cross-sectional analytical research design was adopted. Data was collected from patients who were using NHIF cards, who were drawn from health facilities. Data was collected using a structured questionnaire where some of the questions were rated using the Likert scale to enable the generation of descriptive statistics. Data was analysed using descriptive and inferential statistics which was conducted with the aid of SPSS version 25. Bivariate analysis was conducted utilizing Chi-square to facilitate the comparison of the independent and the dependent variables. Data was presented in tabular formats where each of the specific objectives was used as parameters of interest to the study. Results The study found that four independent variables (Patient knowledge of NHIF Benefit Package, NHIF Premium Payment processes, Selecting NHIF capitated Health Facility, and NHIF Communication to citizens) were significant predictors of access to capitated healthcare services with significance values of .001, .001, .001 and .001 respectively at 95% significance level. Conclusions The study found that familiarity with the NHIF benefit package significantly influenced NHIF capitated members' access to primary healthcare services in Uasin Gishu County. While most members were aware of their healthcare entitlements, there's a need for increased awareness regarding access to surgical services and dependents' inclusion. Facility selection also played a crucial role, influenced by factors like freedom of choice, NHIF facility selection rules, facility appearance, and proximity to members' homes. NHIF communication positively impacted access, with effective communication channels aiding service accessibility. Premium payment processes also significantly linked with service access, influenced by factors such as payment procedures, premium awareness, payment schedules, registration waiting periods, and penalties for defaults. Overall, patient knowledge, NHIF communication, premium payment processes, and facility selection all contributed positively to NHIF capitated members' access to primary healthcare services in Uasin Gishu County. Capitation National Hospital Insurance Fund Universal Health Coverage Introduction Health financing plays a critical role in the functioning of healthcare systems, encompassing the acquisition, pooling, and allocation of funds to address people’s healthcare needs 1 . An effective health financing system should be capable of consistently generating sufficient funds to facilitate access to high-quality health services without imposing financial burdens 2 . The core functions of health financing comprise revenue collection, risk pooling, and the purchasing of health services 3 . Purchasing can take either a passive or strategic approach. Strategic purchasing aims to optimize health system performance, while passive purchasing operates within predetermined budgetary constraints. Strategic purchasing, integral to achieving Universal Health Coverage (UHC), prioritizes both adequate resource mobilization and efficient resource utilization 4 . Provider payment mechanisms within healthcare systems primarily include fee-for-service, salary, and capitation. Strategic employment of capitation holds promise for advancing UHC objectives. Capitation involves providers receiving fixed payments per enrolled individual over a defined period, fostering a shift towards preventive care 5 . Simplified billing procedures under capitation streamline administrative processes and incentivize preventive healthcare, thus reducing reliance on costly interventions 6-7 . Globally, the capitation model predominates in tax-funded health systems like those of Italy and the UK, where general practitioners deliver primary care 8 . As countries commit to UHC, many are considering integrating capitation with other payment models to enhance healthcare efficiency and performance 8, 9 . However, challenges such as inadequate incentive structures and concerns about limiting consumer choice hinder widespread adoption 10 . Kenya's National Hospital Insurance Fund (NHIF) predominantly employs capitation to finance primary healthcare services, contracting various organizations to provide outpatient care. Despite the theoretical benefits of capitation in promoting preventive care and reducing hospitalization rates, challenges persist, including inadequate funding and delays in payment 15, 17 . Kenya's efforts to achieve UHC through NHIF expansion face obstacles such as reliance on out-of-pocket payments and inconsistencies in service provision 18-20 . To address these challenges, this study was conducted in Uasin Gishu County, Kenya, to explore factors influencing access to primary healthcare services among NHIF capitated members. The findings aim to inform decision-makers and stakeholders on measures to enhance access to primary healthcare services within the national scheme. Methods This cross-sectional analytical research was conducted in Uasin Gishu County, Kenya, chosen due to its large population exceeding 1.3 million in 2019 and a notable inter-censual growth rate of 3.6%, surpassing the national rate of 2.9% 48 . The county's poverty rate, at 44.6% as of 2006, highlights socio-economic disparities affecting the purchasing power of primary healthcare services. Among its 125 public health facilities, there's one national referral hospital, two district hospitals, 11 sub-district hospitals, 88 dispensaries, and 23 health centres. Utilizing a multistage sampling technique, 90 facilities were selected, targeting over 10,000 capitated members. Based on Krejcie and Morgan's formula, a sample of 384 respondents was determined, proportionately allocated to the facilities according to NHIF registration. Within each facility, simple random sampling was employed. Data collection utilized a structured questionnaire, employing a three-point Likert scale, administered in english, covering socio-demographic characteristics, independent variables (NHIF Benefit Package, premium payment processes, communication to citizens, and healthcare provider selection), and the dependent variable (access to NHIF primary healthcare services). Logistic regression analysed the relationship between independent and dependent variables, with Likert scale responses converted into binary variables, where agreement was coded as 1 and disagreement or not sure as 0. This binary coding facilitated the analysis, reflecting patients' access or lack thereof to primary healthcare services. Results 282 out of 384 participants responded, contributing to a 73% response rate, ideal for analysing socio-demographic characteristics such as gender, age, number of children, marital status, education, employment, household income, and NHIF contributions as presented in Table 1. Table 1: Socio-Demographic Characteristics of the sample (n = 282) Description Frequency (n) Percentage (%) Gender Male 143 51 Female 139 49 Age 18-24 31 11 25-34 124 44 35-44 43 15 45-54 19 7 55-64 6 2 Above 65 1 Marital Status Single 111 39 Married 130 46 Cohabiting 19 7 Separated 12 4 Divorced 3 1 Widowed 5 2 Number of Children None 43 15 1-2 163 58 3-4 18 6 Level of Education None 4 1 Primary 11 4 Secondary 55 20 College 129 46 University 80 28 Employment Employed 126 45 Self Employed 123 43 Student 31 11 Monthly Household Income (KShs.) Less than 10,000 71 25 10,001-20,000 62 22 20,001-30,000 68 24 30,001-40,000 39 14 40,001-50,000 15 5 Above 50,001 20 7 NHIF Monthly premium (KShs.) None 3 1 100-500 125 44 501-1000 66 23 1001-1500 13 5 1501-2000 19 6 Above 2000 5 1 The primary age group of respondents was 25 to 34 years, typically productive and focused on personal and organizational growth. They exhibited a high likelihood of seeking healthcare services, with many having young families, leading to increased capitation subscription, contribution, and utilization rates. The majority had partners, had 1-2 children, had acquired tertiary education, had employment, and had a household income adequate for NHIF premiums. Table 2: Patient perception of NHIF Benefit package, NHIF Communication to citizens, Selecting Healthcare Provider and Premium payment process NHIF Primary Health Service Benefits Disagree Not Sure Agree n(%) n(%) n(%) i.General Consultation 23(09) 07(02) 252(89) ii. Basic Lab Investigations 23(09) 29(10) 230(82) iii. Prescription & administration of drugs 30(10) 24(09) 228(81) iv. Minor surgical procedures 44(15) 28(10) 210(74) v. Inclusion of dependents 34(12) 38(13) 210(74) NHIF Communication to Citizens i. NHIF communicates to me regularly through SMS, Newspaper, Radio, TV 54(19) 18(06) 210(75) ii. NHIF uses a language I understand 22(07) 15(05) 245(87) iii. NHIF guides me in the process of registration 44(16) 43(15) 195(69) iv. NHIF provides me with all the information I require and need to know 47(17) 49(17) 186(66) v. NHIF states the range of services offered in each benefit package 53(19) 38(13) 191(68) vi. NHIF always responds to public complaints and feedback 93(33) 45(16) 144(51) Selecting Primary Healthcare Provider i. NHIF communicates the rules for selecting a healthcare facility 36(12) 38(13) 208(74) ii. NHIF provides an adequate number of health facilities for patients to choose from 54(19) 39(14) 189(67) iii. I can choose more than one facility under NHIF contracted facilities 74(26) 41(15) 167(59) iv. I choose the facility at my free will 35(12) 33(12) 214(76) v. The facility is close to my home 55(19) 23(08) 204(72) vi. Physical facilities are visually appealing 41(15) 29(10) 212(75) Premium Payment Process i. Am aware of the amount of monthly premium paid 15(05) 19(07) 248(88) ii. Am aware of the process of paying NHIF contributions 18(07) 26(09) 238(84) iii. There are penalties in case of defaulting NHIF premiums for 3 months 41(15) 45(16) 196(70) iv. Premium payment schedule is on 10 th of every month. 27(10) 26(09) 229(81) v. Waiting period to access primary care services after registration 41(15) 40(14) 201(71) The study evaluated respondents' perception of the NHIF Benefit package, focusing on outpatient benefits like general consultations, basic lab investigations, prescriptions, minor surgical procedures, and inclusion of dependents. Majority of the respondents 252(89%) agreed that general consultation was one of the benefits, followed by basic lab investigations 230(82%), prescriptions and administration of drugs 228(81%), treatment for local diseases, 227(80%) and minor surgical procedures and inclusion of dependents 210(74%). Most respondents 245(87%) acknowledged NHIF's use of understandable language in communication, with regular updates 210(75%) through SMS, newspapers, radio, and TV. Additionally, 195(69%) agreed that NHIF assists in registration, 191(68%) specifies service packages, 186(66%) provides necessary information, and 144(51%) addresses public feedback. Most respondents 218(76%) affirmed their ability to freely select registered primary healthcare providers, finding facilities visually appealing 212(75%), understanding selection rules 208(74%), and appreciating proximity to their homes 204(72%). However, a minority 74(26%) disagreed with selecting multiple facilities, and some 54(19%) felt NHIF didn't offer sufficient options for selecting healthcare facilities. The NHIF Premium Payment processes, including monthly premiums, payment procedures, penalties for defaulting, payment schedule, waiting period after registration, and access to health services, were evaluated. Results showed strong agreement across variables, with the highest scores for monthly premiums 248(88%), payment procedures 238(84%), and payment schedule 229(81%). However, knowledge of waiting periods 201(71%) and defaulting penalties 196(70%) scored lower. Access to NHIF Primary Care Health Services The study dependent variable was patient’s access to NHIF Primary Care Health Services. Descriptive results are presented in Table 2. Table 2: Access to NHIF Primary Care Health Services To what extent do you agree with the following statements. Disagree Not Sure Agree n (%) n (%) n (%) i. Service providers are always willing to help patient 56(20) 23(8) 203(72) ii. Service providers give patients personal attention 58(20) 34(12) 190(67) iii. I feel safe while interacting with the hospital employees 47(17) 25(09) 210(74) iv. Attitude of the service providers is good 46(16) 26(09) 210(75) v. I get all prescribed drugs and services at the facility 101(36) 34(12) 147(52) vi. The staff are trained and qualified 31(11) 48(17) 203(72) vii. I have access to all NHIF outpatient services 57(20) 40(14) 185(66) viii. The waiting time is often not too long 77(27) 34(12) 171(61) ix. NHIF prescribed services are always available 68(24) 41(15) 173(61) x. I am never asked to co-pay for registration, consultation, medications, or laboratory services 226(80) 24(09) 32(11) Over 70% agreement was observed regarding positive staff attitude, feeling safe while with staffs, staff competence and willingness to assist patients, NHIF service availability, and manageable waiting times. However, 226(80%) agreed to paying out-of-pocket for registration, consultation, medications, or laboratory services. Chi-square results indicate significant associations between knowledge of NHIF benefit package (χ² = 57.597, p < 0.01), NHIF premium payment (χ² = 39.498, p < 0.001), selecting NHIF healthcare providers (χ² = 63.573, p < 0.001), and NHIF communication (χ² = 48.355, p < 0.001) with patients' access to NHIF primary care services. Logistic regression analysis revealed that familiarity with NHIF benefit package increased access by 26.00 times, knowledge of premium payment by 12.49 times, understanding provider selection rules by 12.03 times, and awareness of communication strategy by 8.38 times. Discussion The predominant age group among respondents was between 25 and 34 years, representing individuals at their peak productivity and deeply invested in personal and professional growth. This cohort exhibited the highest likelihood of seeking healthcare services, leading to increased rates of capitation subscription, contribution, and utilization. Married couples showed a higher rate of insurance coverage, attributed to their responsibilities towards dependents and a comparatively higher household income, facilitating premium payments. Moreover, a majority of respondents had attained at least minimum academic and professional qualifications, enhancing their understanding of NHIF procedures and terms. They also boasted household incomes adequate for monthly NHIF contributions. However, patient awareness of NHIF primary health service benefits remained limited, with approximately 25% expressing disagreement or uncertainty regarding their entitlements 53 . Understanding of NHIF benefits significantly influenced access to capitated health services positively. While NHIF continuously reviews its benefit package, many members only become aware of the outpatient services when they necessitate them, possibly due to the on-demand nature of outpatient care utilization 34 . Effective communication from NHIF positively impacted access to primary care health services under capitation. Despite positive feedback regarding NHIF's provision of necessary information, a significant portion of respondents expressed dissatisfaction with NHIF's responsiveness to public complaints and its clarity regarding service packages. NHIF primarily communicates through its website and media advertisements, but the limited reach of these channels potentially hinders members' awareness of their entitlements, affecting healthcare access and potentially leading to under or over-provision of services 15 . Equity and efficiency in healthcare provision can be achieved by empowering the service providers and the members with the information by adopting effective communication channels 55 . The findings agree with other studies which show that some of the communication media used by the NHIF included television, radio, newspaper, social media, mobile phones, billboards, and sensitization campaigns 32 . They agree with the findings of another study where reportedly 57% of the respondents are provided information by NHIF while 43% are not receiving any communication from NHIF regarding the health services covered 53 . In addition, the results also highlight that no legislation provides for feedback or complaints mechanism from members or beneficiaries 15 . Approximately 20% of respondents were unaware of the premium payment process, indicating a lack of clarity regarding NHIF contributions 54 . The perception of NHIF-accredited health facilities significantly influenced service utilization, with patients associating the facilities' image with service quality 34 . However, the accreditation status varied among clinics and higher-level facilities, potentially impacting service uptake 43 . Additionally, individuals diagnosed with chronic illnesses exhibited a higher likelihood of selecting healthcare providers and utilizing services, with private providers restricted to specific service categories compared to government hospitals 24 . Limitations Using structured questions to collect self-reported data. Participants may provide inaccurate or biased responses due to social desirability bias or recall bias. Additionally, respondents' comprehension of the questions or their willingness to disclose certain information could vary, leading to inconsistencies in the data collected. This could affect the validity and reliability of the study's findings. The findings of the research may have limited generalizability beyond the specific context of Uasin Gishu County. Factors influencing access to primary healthcare services can vary significantly depending on geographical location, cultural norms, healthcare infrastructure, and other contextual factors. Therefore, the determinants identified in this study may not be applicable to capitated members in other regions of Kenya or in different counties; limiting the broader applicability of the research findings and the study also targeted NHIF accredited public health facilities in Uasin Gishu County, Kenya. Privately owned hospitals were excluded. Hence the study findings can be generalized to public facilities. Conclusions NHIF capitated members are generally aware of their healthcare entitlement. However, efforts are needed to enhance more awareness regarding entitlement to surgical services, inclusion of dependents, access to information about the benefit package, feedback and complaint mechanisms, premium payment process, awareness of the premium to be paid, payment schedule, the waiting period before registration and accessing services, and penalties in the event of default. This information could be used to advocate for the implementation of effective communication systems that allow for real-time dissemination of information and feedback, as well as to conduct regular in-service training and recruiting a well-educated workforce that is familiar with NHIF procedures and terms in order to promote the NHIF in the face of capitated members' social-demographic profiles, and to increase knowledge of the health coverage plan for the informal sector and flexible payment platforms. Utilizing vernacular to reach more communities, particularly in rural areas could broaden outreach. Declarations Ethical Considerations Ethical clearance was obtained from Kenya Methodist University Scientific and Ethics Review Committee (KeMU/SERC/HSM/22/2022), the National Commission of Science and Technology and Innovation (NACOSTI/P/22/19153), and the County Director of Health. Participants provided informed consent, assured of confidentiality and anonymity. They were informed of the voluntary nature of participation and their right to withdraw at any time. Competing interests The authors declare that they have no competing interests. Authors’ contributions Barbara Nawire Were and Eunice Muthoni Mwangi conceived the study. Barbara Nawire Were, Eunice Muthoni Mwangi and Lillian Wambui Muiruri participated in the design, its implementation, and analysis. All authors read and approved the final manuscript. Authors’ information The authors have been involved in health systems research activities in Kenya. Acknowledgments I thank the county government of Uasin Gishu-County directors, the healthcare facility managers, service providers and their clients for their support in the study. I am also gratefully to my supervisors Dr. Eunice Muthoni Mwangi and Ms. Lillian Wambui Muiruri for their guidance through the process from inception to ensuring the objective of this study is achieved. References World Health Organization. The world health report: health systems financing: the path to universal coverage: executive summary. World Health Organization; 2010. Liaropoulos L, Goranitis I. Health care financing and the sustainability of health systems. International Journal for Equity in Health. 2015 Dec; 14(1):1-4. World Health Organization. An empirical model of access to health care, health care expenditure and impoverishment in Kenya: learning from past reforms and lessons for the future. World Health Organization; 2006. Honda A. What is strategic purchasing for health? 2014. Langenbrunner J, Cashin C, O'Dougherty S, editors. Designing and implementing health care provider payment systems: how-to manuals. World Bank Publications; 2009. James BC MD. The Case for Capitation [Internet]. Harvard Business Review. 2016. Available from: https://hbr.org/2016/07/the-case-for-capitation. Busby M, Chapple L, Clover H, McCreanor J, Chapple I. Capitation care fee banding: aspects of reliability and validity of an online tool. British Dental Journal. 2018 Oct 26; 225(8):751-5. Park M, Braun T, Carrin G, Evans DB, World Health Organization. Provider payments and cost-containment: lessons from OECD countries. World Health Organization; 2007. Feldhaus I, Mathauer I. Effects of mixed provider payment systems and aligned cost sharing practices on expenditure growth management, efficiency, and equity: a structured review of the literature. BMC health services research. 2018 Dec; 18:1-4. Koenecke A. A game theoretic setting of capitation versus fee-for-service payment systems. Plos one. 2019 Oct 7; 14(10):e0223672. Lagomarsino G, Garabrant A, Adyas A, Muga R, Otoo N. Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. The Lancet. 2012 Sep 8; 380(9845):933-43. Abiiro GA, Alatinga KA, Yamey G. Why did Ghana’s national health insurance capitation payment model fall off the policy agenda? A regional level policy analysis. Health Policy and Planning. 2021 Jul 1; 36(6):869-80. Alawode GO, Adewole DA. Assessment of the design and implementation challenges of the National Health Insurance Scheme in Nigeria: a qualitative study among sub-national level actors, healthcare and insurance providers. BMC Public Health. 2021 Dec; 21(1):1-2. Nyandekwe M, Nzayirambaho M, Kakoma JB. Universal health insurance in Rwanda: major challenges and solutions for financial sustainability case study of Rwanda community-based health insurance part I. Pan African Medical Journal. 2020 Sep 14; 37(1). Munge K, Mulupi S, Barasa EW, Chuma J. A critical analysis of purchasing arrangements in Kenya: the case of the National Hospital Insurance Fund. International journal of health policy and management. 2018 Mar; 7(3):244. Obadha M, Chuma J, whongu J, Abiiro GA, Beck MJ, Barasa E. Preferences of healthcare providers for capitation payment in Kenya: a discrete choice experiment. Health Policy and Planning. 2020 Aug; 35(7):842-54. Obadha M, Chuma J, Kazungu J, Barasa E. Health care purchasing in Kenya: Experiences of health care providers with capitation and fee‐for‐service provider payment mechanisms. The International Journal of Health Planning and Management. 2019 Jan; 34(1):e917-33. Barasa EW, Maina T, Ravishankar N. Assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in Kenya. International journal for equity in health. 2017 Dec; 16(1):1-4. Barasa E, Nguhiu P, McIntyre D. Measuring progress towards sustainable development goal 3.8 on universal health coverage in Kenya. BMJ global health. 2018 Jun 1; 3(3):e000904. Eunice MM, Tenambergen W, Mapesa J, Mutai I. Citizen engagement in social health insurance purchasing, in selected counties in Kenya. Krejcie RV, Morgan DW. Determining sample size for research activities. Educational and psychological measurement. 1970 Sep; 30(3):607-10. Sachs JD. Achieving universal health coverage in low-income settings. The Lancet. 2012 Sep 8; 380(9845):944-7. Xu W, Cai GJ, Li GN, Cao JJ, Shi QH, Bai J. Age or health status: which influences medical insurance enrollment greater? Journal of global health. 2016 Dec; 6(2). Mwaura GW, Kamano JH, Mwangi AW, Lusimbo L, Mugo R, Too K, Andale T, Itsura P, Kibachio J, Gathecha G, Aruasa W. Awareness, Uptake and factors associated with NHIF uptake in Western Kenya: A case of 4 counties-Busia, Trans Nzoia, Vihiga and Siaya. Chuma J, Maina T. Catastrophic health care spending and impoverishment in Kenya. BMC health services research. 2012 Dec; 12(1):1-9. Salari P, Di Giorgio L, Ilinca S, Chuma J. The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ global health. 2019 Nov 1;4(6):e001809. Njagi P, Arsenijevic J, Groot W. Decomposition of changes in socioeconomic inequalities in catastrophic health expenditure in Kenya. PLoS One. 2020 Dec 29; 15(12):e0244428. Nyman JA. The theory of demand for health insurance. Stanford University Press; 2003. Explanation of the benefit package for the National Scheme [Internet]. 2015. Available from: http://publications.universalhealth2030.org/uploads/nhif_benefits_package.pdf Ongiri IS, Kubani JA. Unions demand talks on NHIF rates. Daily Nation. 2015:17. Mulupi S, Kirigia D, Chuma J. Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya. BMC health services research. 2013 Dec; 13(1):1-2. Mbau R, Kabia E, Honda A, Hanson K, Barasa E. Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya. International journal for equity in health. 2020 Dec; 19:1-8. World Health Organization. (2008). Health System Financing. Retrieved from https://www.who.int/healthinfo/statistics/toolkit_hss/EN_PDF_Toolkit_HSS_Financing.pdf Kironji KM, Tenambergen WM, Mwangi EM. Effects of Perceived Image of NHIF Outpatient Facilities on Utilization of Primary Care Services by Private University Employees in Nairobi County. Ochieng DL. Factors influencing uptake of national hospital insurance fund cover by rural households in Kasipul division, Rachuonyo south sub county, Homa Bay County (Doctoral dissertation, University of Nairobi). Otieno PO, Wambiya EO, Mohamed SM, Mutua MK, Kibe PM, Mwangi B, Donfouet HP. Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya. BMC Public Health. 2020 Dec; 20:1-9. Pauly MV. The economics of moral hazard: comment. The american economic review. 1968 Jun 1; 58(3):531-7. Clark T, Foster L, Bryman A, Sloan L. Bryman's social research methods. Oxford University Press; 2021. Orangi S, Kairu A, Malla L, Ondera J, Mbuthia B, Ravishankar N, Barasa E. Impact of free maternity policies in Kenya: an interrupted time-series analysis. BMJ Global Health. 2021 Jun 1; 6(6):e003649. Jowett M. Theoretical insights into the development of health insurance in low-income countries. 2004 Mar. Ilinca S, Di Giorgio L, Salari P, Chuma J. Socio-economic inequality and inequity in use of health care services in Kenya: evidence from the fourth Kenya household health expenditure and utilization survey. International journal for equity in health. 2019 Dec; 18:1-3. Suchman L. Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study. International journal for equity in health. 2018 Dec; 17:1-8. Sieverding M, Onyango C, Suchman L. Private healthcare provider experiences with social health insurance schemes: findings from a qualitative study in Ghana and Kenya. PLoS One. 2018 Feb 22; 13(2):e0192973. Einav L, Finkelstein A. Moral hazard in health insurance: what we know and how we know it. Journal of the European Economic Association. 2018 Aug 1; 16(4):957-82. Rono GJ. Out-Of-Pocket Payment for Healthcare and Its Effects on Household Welfare in Rural and Urban Areas of Kenya [Internet]. 2017. Available from: https://ir-library.ku.ac.ke/handle/123456789/17969 World Health Organization. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. World Health Organization; 2010. Morris S, Devlin N, Parkin D, Spencer A. Health insurance and healthcare financing. Economic Analysis in Health Care. Chichester: John Wiley and Sons Ltd. 2007:149-82. KNBS K. Kenya Population and Housing Census Volume I: Population by County and Sub-County. Vol. I. 2019; 2019. Mugenda OM, Mugenda AG. Research methods: Quantitative & qualitative approaches. Nairobi: Acts press; 2003. Chuma J, Maina T. Catastrophic health care spending and impoverishment in Kenya. BMC Health Serv Res. 2012;12(1):1–9. Kituku AM, Amata E, Wachira M. Determinants of the uptake of NHIF medical cover by informal sector workers: A case of UNAITAS SACCO members in Muranga County. 2016; Ndungu TT. Factors influencing uptake of national health insurance in the informal sector: a case of ithanga division in murang’a county, Kenya. University of Nairobi; 2015. Mwangi EM, Tenambergen W, Mapesa J, Mutai I. Citizen engagement in social health insurance purchasing, in selected counties in Kenya. Int J Community Med Public Heal. 2019;6(10):4145–53. Namuhisa JA. Determinants of uptake of National Hospital Insurance Fund scheme by the informal sector in Nairobi county, Kenya. Unpubl MBA Proj Kenyatta Univ Kenya. 2014 Guy Carrin, Chris James, Key Performance Indicators for the Implementation of Social Health Insurance, Applied Health Economics and Health Policy, 10.2165/00148365-200504010-00004, 4 , 1, (15-22), (2005). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Sep, 2024 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 11 Apr, 2024 Submission checks completed at journal 05 Apr, 2024 Editor assigned by journal 05 Apr, 2024 First submitted to journal 11 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3949354","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":288110806,"identity":"806deb4e-7cfb-41eb-bda0-2f30e45cf4c8","order_by":0,"name":"Barbara Were","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYLACxgYGBgMQ4wMQs7GTooVxBkgLMylamHlAPEJaDI73PnxcuMMu35z97MPPNr+2yfMxMzB++JiDR8uZ48bGM88kW+7sSTeWzu27bdjGzMAsOXMbbi1mN9LYpHnbmA0MDqQxSOf23GYEamFj5sWn5f4z9t+8bfUGBuefMf+27LltT1jLDTaggrbDBgYg6xh+3E4kqMX+TBqzNO+Z4waWM56xWfY23E5uY2ZsxusXyfZjjJ95d1QbmPOnMd/48ee27fz25oMfPuLRggoY28BkA7HqQeAPKYpHwSgYBaNgpAAAnOxMyRW38vcAAAAASUVORK5CYII=","orcid":"","institution":"Kenya Methodist University","correspondingAuthor":true,"prefix":"","firstName":"Barbara","middleName":"","lastName":"Were","suffix":""},{"id":288110808,"identity":"e7108cc0-a0a5-46e0-8a85-160e920e47cd","order_by":1,"name":"Eunice Mwangi","email":"","orcid":"","institution":"Aga Khan University-East Africa","correspondingAuthor":false,"prefix":"","firstName":"Eunice","middleName":"","lastName":"Mwangi","suffix":""},{"id":288110810,"identity":"e69b1095-481a-40fc-9bb6-b50bb3d0d47c","order_by":2,"name":"Lillian Muiruri","email":"","orcid":"","institution":"Kenya Methodist University","correspondingAuthor":false,"prefix":"","firstName":"Lillian","middleName":"","lastName":"Muiruri","suffix":""}],"badges":[],"createdAt":"2024-02-11 21:01:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3949354/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3949354/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-024-11282-8","type":"published","date":"2024-09-04T16:08:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64186214,"identity":"a78caf39-98ac-4f57-b28c-18c3b0a4dfe5","added_by":"auto","created_at":"2024-09-09 16:25:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":633086,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3949354/v1/1b14303d-a992-476a-99ee-d2c802db4862.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eDeterminants of Primary Healthcare Services Access by National Health Insurance Fund Capitated Members in Uasin Gishu County, Kenya\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHealth financing plays a critical role in the functioning of healthcare systems, encompassing the acquisition, pooling, and allocation of funds to address people’s healthcare needs\u003csup\u003e1\u003c/sup\u003e. An effective health financing system should be capable of consistently generating sufficient funds to facilitate access to high-quality health services without imposing financial burdens\u003csup\u003e2\u003c/sup\u003e. The core functions of health financing comprise revenue collection, risk pooling, and the purchasing of health services\u003csup\u003e3\u003c/sup\u003e. Purchasing can take either a passive or strategic approach. Strategic purchasing aims to optimize health system performance, while passive purchasing operates within predetermined budgetary constraints. Strategic purchasing, integral to achieving Universal Health Coverage (UHC), prioritizes both adequate resource mobilization and efficient resource utilization\u003csup\u003e4\u003c/sup\u003e. Provider payment mechanisms within healthcare systems primarily include fee-for-service, salary, and capitation. Strategic employment of capitation holds promise for advancing UHC objectives. Capitation involves providers receiving fixed payments per enrolled individual over a defined period, fostering a shift towards preventive care\u003csup\u003e5\u003c/sup\u003e. Simplified billing procedures under capitation streamline administrative processes and incentivize preventive healthcare, thus reducing reliance on costly interventions\u003csup\u003e6-7\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eGlobally, the capitation model predominates in tax-funded health systems like those of Italy and the UK, where general practitioners deliver primary care\u003csup\u003e8\u003c/sup\u003e. As countries commit to UHC, many are considering integrating capitation with other payment models to enhance healthcare efficiency and performance\u003csup\u003e8, 9\u003c/sup\u003e. However, challenges such as inadequate incentive structures and concerns about limiting consumer choice hinder widespread adoption\u003csup\u003e10\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eKenya's National Hospital Insurance Fund (NHIF) predominantly employs capitation to finance primary healthcare services, contracting various organizations to provide outpatient care. Despite the theoretical benefits of capitation in promoting preventive care and reducing hospitalization rates, challenges persist, including inadequate funding and delays in payment\u003csup\u003e15, 17\u003c/sup\u003e. Kenya's efforts to achieve UHC through NHIF expansion face obstacles such as reliance on out-of-pocket payments and inconsistencies in service provision\u003csup\u003e18-20\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTo address these challenges, this study was conducted in Uasin Gishu County, Kenya, to explore factors influencing access to primary healthcare services among NHIF capitated members. The findings aim to inform decision-makers and stakeholders on measures to enhance access to primary healthcare services within the national scheme.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis cross-sectional analytical research was conducted in Uasin Gishu County, Kenya, chosen due to its large population exceeding 1.3 million in 2019 and a notable inter-censual growth rate of 3.6%, surpassing the national rate of 2.9%\u003csup\u003e48\u003c/sup\u003e. The county's poverty rate, at 44.6% as of 2006, highlights socio-economic disparities affecting the purchasing power of primary healthcare services. Among its 125 public health facilities, there's one national referral hospital, two district hospitals, 11 sub-district hospitals, 88 dispensaries, and 23 health centres. Utilizing a multistage sampling technique, 90 facilities were selected, targeting over 10,000 capitated members. Based on Krejcie and Morgan's formula, a sample of 384 respondents was determined, proportionately allocated to the facilities according to NHIF registration. Within each facility, simple random sampling was employed.\u003c/p\u003e\n\u003cp\u003eData collection utilized a structured questionnaire, employing a three-point Likert scale, administered in english, covering socio-demographic characteristics, independent variables (NHIF Benefit Package, premium payment processes, communication to citizens, and healthcare provider selection), and the dependent variable (access to NHIF primary healthcare services). Logistic regression analysed the relationship between independent and dependent variables, with Likert scale responses converted into binary variables, where agreement was coded as 1 and disagreement or not sure as 0. This binary coding facilitated the analysis, reflecting patients' access or lack thereof to primary healthcare services.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e282 out of 384 participants responded, contributing to a 73% response rate, ideal for analysing socio-demographic characteristics such as gender, age, number of children, marital status, education, employment, household income, and NHIF contributions as presented in Table 1.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003eTable\u0026nbsp;1: Socio-Demographic Characteristics\u0026nbsp;of the sample (n = 282)\u003c/h3\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"542\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e18-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e25-34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e35-44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e45-54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e55-64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eAbove 65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eCohabiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eSeparated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Children\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e1-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e3-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eSelf Employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonthly Household Income (KShs.)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eLess than 10,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e10,001-20,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e20,001-30,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e30,001-40,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e40,001-50,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eAbove 50,001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNHIF Monthly premium (KShs.)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e100-500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e501-1000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e1001-1500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003e1501-2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.95940959409594%\" valign=\"top\"\u003e\n \u003cp\u003eAbove 2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.210332103321036%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.830258302583026%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe primary age group of respondents was 25 to 34 years, typically productive and focused on personal and organizational growth. They exhibited a high likelihood of seeking healthcare services, with many having young families, leading to increased capitation subscription, contribution, and utilization rates. The majority had partners, had 1-2 children, had acquired tertiary education, had employment, and had a household income adequate for NHIF premiums.\u003c/p\u003e\n\u003ch3\u003eTable\u0026nbsp;2: Patient perception of NHIF Benefit package, NHIF Communication to citizens, Selecting Healthcare Provider and Premium payment process\u003c/h3\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"636\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNHIF Primary Health Service Benefits\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot Sure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAgree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.771929824561404%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.64912280701754%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.57894736842105%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003ei.General Consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e23(09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e07(02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e252(89)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003eii. Basic Lab Investigations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e23(09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e29(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e230(82)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003eiii. Prescription \u0026amp; administration of drugs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e30(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e24(09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e228(81)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003eiv. Minor surgical procedures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e44(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e28(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e210(74)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003ev. Inclusion of dependents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e34(12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e38(13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e210(74)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNHIF Communication to Citizens\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003ei. NHIF communicates to me regularly through SMS, Newspaper, Radio, TV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e54(19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e18(06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e210(75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003eii. NHIF uses a language I understand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e22(07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e15(05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e245(87)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003eiii. NHIF guides me in the process of registration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e44(16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e43(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e195(69)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003eiv. NHIF provides me with all the information I require and need to know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e47(17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e49(17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e186(66)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003ev. NHIF states the range of services offered in each benefit package\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e53(19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e38(13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e191(68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003evi. NHIF always responds to public complaints and feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e93(33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e45(16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e144(51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelecting Primary Healthcare Provider\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003ei. NHIF communicates the rules for selecting a healthcare facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e36(12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e38(13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e208(74)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003eii. NHIF provides an adequate number of health facilities for patients to choose from\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e54(19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e39(14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e189(67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003eiii. I can choose more than one facility under NHIF contracted facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e74(26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e41(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e167(59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003eiv. I choose the facility at my free will\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e35(12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e33(12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e214(76)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003ev. The facility is close to my home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e55(19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e23(08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e204(72)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003evi. Physical facilities are visually appealing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e41(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e29(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e212(75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePremium Payment Process\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003ei. Am aware of the amount of monthly premium paid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e15(05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e19(07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e248(88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003eii. Am aware of the process of paying NHIF contributions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e18(07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e26(09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e238(84)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003eiii. There are penalties in case of defaulting NHIF premiums for 3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e41(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e45(16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e196(70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003eiv. Premium payment schedule is on 10\u003csup\u003eth\u003c/sup\u003e of every month.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e27(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e26(09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e229(81)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.2072213500785%\" valign=\"top\"\u003e\n \u003cp\u003ev. Waiting period to access primary care services after registration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.087912087912088%\" valign=\"top\"\u003e\n \u003cp\u003e41(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.40188383045526%\" valign=\"top\"\u003e\n \u003cp\u003e40(14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e201(71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;The study evaluated respondents\u0026apos; perception of the NHIF Benefit package, focusing on outpatient benefits like general consultations, basic lab investigations, prescriptions, minor surgical procedures, and inclusion of dependents. Majority of the respondents 252(89%) agreed that general consultation was one of the benefits, followed by basic lab investigations 230(82%), prescriptions and administration of drugs 228(81%), treatment for local diseases, 227(80%) and minor surgical procedures and inclusion of dependents 210(74%). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost respondents 245(87%) acknowledged NHIF\u0026apos;s use of understandable language in communication, with regular updates 210(75%) through SMS, newspapers, radio, and TV. Additionally,\u0026nbsp;195(69%) agreed that NHIF assists in registration,\u0026nbsp;191(68%)\u0026nbsp;specifies service packages,\u0026nbsp;186(66%)\u0026nbsp;provides necessary information, and\u0026nbsp;144(51%)\u0026nbsp;addresses public feedback.\u003c/p\u003e\n\u003cp\u003eMost respondents 218(76%) affirmed their ability to freely select registered primary healthcare providers, finding facilities visually appealing 212(75%), understanding selection rules 208(74%), and appreciating proximity to their homes 204(72%). However, a minority 74(26%) disagreed with selecting multiple facilities, and some 54(19%) felt NHIF didn\u0026apos;t offer sufficient options for selecting healthcare facilities.\u003c/p\u003e\n\u003cp\u003eThe NHIF Premium Payment processes, including monthly premiums, payment procedures, penalties for defaulting, payment schedule, waiting period after registration, and access to health services, were evaluated. Results showed strong agreement across variables, with the highest scores for monthly premiums 248(88%), payment procedures 238(84%), and payment schedule 229(81%). However, knowledge of waiting periods 201(71%) and defaulting penalties 196(70%) scored lower.\u003c/p\u003e\n\u003ch3\u003eAccess to NHIF Primary Care Health Services\u003c/h3\u003e\n\u003cp\u003eThe study dependent variable was patient\u0026rsquo;s access to NHIF Primary Care Health Services. Descriptive results are presented in Table 2.\u003c/p\u003e\n\u003ch3\u003eTable 2: Access to NHIF Primary Care Health Services\u003c/h3\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"629\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.95707472178061%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTo what extent do you agree with the following statements.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.354531001589825%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.400635930047695%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot Sure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.287758346581876%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAgree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.05150214592275%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.47639484978541%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.472103004291846%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.95707472178061%\" valign=\"top\"\u003e\n \u003cp\u003ei. Service providers are always willing to help patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.354531001589825%\" valign=\"top\"\u003e\n \u003cp\u003e56(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.400635930047695%\" valign=\"top\"\u003e\n \u003cp\u003e23(8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.287758346581876%\" valign=\"top\"\u003e\n \u003cp\u003e203(72)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.95707472178061%\" valign=\"top\"\u003e\n \u003cp\u003eii. Service providers give patients personal attention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.354531001589825%\" valign=\"top\"\u003e\n \u003cp\u003e58(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.400635930047695%\" valign=\"top\"\u003e\n \u003cp\u003e34(12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.287758346581876%\" valign=\"top\"\u003e\n \u003cp\u003e190(67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.95707472178061%\" valign=\"top\"\u003e\n \u003cp\u003eiii. I feel safe while interacting with the hospital employees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.354531001589825%\" valign=\"top\"\u003e\n \u003cp\u003e47(17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.400635930047695%\" valign=\"top\"\u003e\n \u003cp\u003e25(09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.287758346581876%\" valign=\"top\"\u003e\n \u003cp\u003e210(74)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.95707472178061%\" valign=\"top\"\u003e\n \u003cp\u003eiv. Attitude of the service providers is good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.354531001589825%\" valign=\"top\"\u003e\n \u003cp\u003e46(16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.400635930047695%\" valign=\"top\"\u003e\n \u003cp\u003e26(09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.287758346581876%\" valign=\"top\"\u003e\n \u003cp\u003e210(75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.95707472178061%\" valign=\"top\"\u003e\n \u003cp\u003ev. I get all prescribed drugs and services at the facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.354531001589825%\" valign=\"top\"\u003e\n \u003cp\u003e101(36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.400635930047695%\" valign=\"top\"\u003e\n \u003cp\u003e34(12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.287758346581876%\" valign=\"top\"\u003e\n \u003cp\u003e147(52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.95707472178061%\" valign=\"top\"\u003e\n \u003cp\u003evi. The staff are trained and qualified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.354531001589825%\" valign=\"top\"\u003e\n \u003cp\u003e31(11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.400635930047695%\" valign=\"top\"\u003e\n \u003cp\u003e48(17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.287758346581876%\" valign=\"top\"\u003e\n \u003cp\u003e203(72)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.95707472178061%\" valign=\"top\"\u003e\n \u003cp\u003evii. I have access to all NHIF outpatient services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.354531001589825%\" valign=\"top\"\u003e\n \u003cp\u003e57(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.400635930047695%\" valign=\"top\"\u003e\n \u003cp\u003e40(14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.287758346581876%\" valign=\"top\"\u003e\n \u003cp\u003e185(66)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.95707472178061%\" valign=\"top\"\u003e\n \u003cp\u003eviii. The waiting time is often not too long\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.354531001589825%\" valign=\"top\"\u003e\n \u003cp\u003e77(27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.400635930047695%\" valign=\"top\"\u003e\n \u003cp\u003e34(12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.287758346581876%\" valign=\"top\"\u003e\n \u003cp\u003e171(61)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.95707472178061%\" valign=\"top\"\u003e\n \u003cp\u003eix. NHIF prescribed services are always available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.354531001589825%\" valign=\"top\"\u003e\n \u003cp\u003e68(24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.400635930047695%\" valign=\"top\"\u003e\n \u003cp\u003e41(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.287758346581876%\" valign=\"top\"\u003e\n \u003cp\u003e173(61)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.95707472178061%\" valign=\"top\"\u003e\n \u003cp\u003ex. I am never asked to co-pay for registration, consultation, medications, or laboratory services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.354531001589825%\" valign=\"top\"\u003e\n \u003cp\u003e226(80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.400635930047695%\" valign=\"top\"\u003e\n \u003cp\u003e24(09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.287758346581876%\" valign=\"top\"\u003e\n \u003cp\u003e32(11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOver 70% agreement was observed regarding positive staff attitude, feeling safe while with staffs, staff competence and willingness to assist patients, NHIF service availability, and manageable waiting times. However, 226(80%) agreed to paying out-of-pocket for registration, consultation, medications, or laboratory services.\u003c/p\u003e\n\u003cp\u003eChi-square results indicate significant associations between knowledge of NHIF benefit package (\u0026chi;\u0026sup2; = 57.597, p \u0026lt; 0.01), NHIF premium payment (\u0026chi;\u0026sup2; = 39.498, p \u0026lt; 0.001), selecting NHIF healthcare providers (\u0026chi;\u0026sup2; = 63.573, p \u0026lt; 0.001), and NHIF communication (\u0026chi;\u0026sup2; = 48.355, p \u0026lt; 0.001) with patients\u0026apos; access to NHIF primary care services. Logistic regression analysis revealed that familiarity with NHIF benefit package increased access by 26.00 times, knowledge of premium payment by 12.49 times, understanding provider selection rules by 12.03 times, and awareness of communication strategy by 8.38 times.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe predominant age group among respondents was between 25 and 34 years, representing individuals at their peak productivity and deeply invested in personal and professional growth. This cohort exhibited the highest likelihood of seeking healthcare services, leading to increased rates of capitation subscription, contribution, and utilization. Married couples showed a higher rate of insurance coverage, attributed to their responsibilities towards dependents and a comparatively higher household income, facilitating premium payments. Moreover, a majority of respondents had attained at least minimum academic and professional qualifications, enhancing their understanding of NHIF procedures and terms. They also boasted household incomes adequate for monthly NHIF contributions.\u003c/p\u003e\n\u003cp\u003eHowever, patient awareness of NHIF primary health service benefits remained limited, with approximately 25% expressing disagreement or uncertainty regarding their entitlements\u003csup\u003e53\u003c/sup\u003e. Understanding of NHIF benefits significantly influenced access to capitated health services positively. While NHIF continuously reviews its benefit package, many members only become aware of the outpatient services when they necessitate them, possibly due to the on-demand nature of outpatient care utilization\u003csup\u003e34\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eEffective communication from NHIF positively impacted access to primary care health services under capitation. Despite positive feedback regarding NHIF's provision of necessary information, a significant portion of respondents expressed dissatisfaction with NHIF's responsiveness to public complaints and its clarity regarding service packages. NHIF primarily communicates through its website and media advertisements, but the limited reach of these channels potentially hinders members' awareness of their entitlements, affecting healthcare access and potentially leading to under or over-provision of services\u003csup\u003e15\u003c/sup\u003e. Equity and efficiency in healthcare provision can be achieved by empowering the service providers and the members with the information by adopting effective communication channels\u003csup\u003e55\u003c/sup\u003e. The findings agree with other studies which show that some of the communication media used by the NHIF included television, radio, newspaper, social media, mobile phones, billboards, and sensitization campaigns\u003csup\u003e32\u003c/sup\u003e. They agree with the findings of another study where reportedly 57% of the respondents are provided information by NHIF while 43% are not receiving any communication from NHIF regarding the health services covered\u003csup\u003e53\u003c/sup\u003e. In addition, the results also highlight that no legislation provides for feedback or complaints mechanism\u0026nbsp;from members or beneficiaries\u003csup\u003e15\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eApproximately 20% of respondents were unaware of the premium payment process, indicating a lack of clarity regarding NHIF contributions\u003csup\u003e54\u003c/sup\u003e. The perception of NHIF-accredited health facilities significantly influenced service utilization, with patients associating the facilities' image with service quality\u003csup\u003e34\u003c/sup\u003e. However, the accreditation status varied among clinics and higher-level facilities, potentially impacting service uptake\u003csup\u003e43\u003c/sup\u003e. Additionally, individuals diagnosed with chronic illnesses exhibited a higher likelihood of selecting healthcare providers and utilizing services, with private providers restricted to specific service categories compared to government hospitals\u003csup\u003e24\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing structured questions to collect self-reported data. Participants may provide inaccurate or biased responses due to social desirability bias or recall bias. Additionally, respondents' comprehension of the questions or their willingness to disclose certain information could vary, leading to inconsistencies in the data collected. This could affect the validity and reliability of the study's findings.\u003c/p\u003e\n\u003cp\u003eThe findings of the research may have limited generalizability beyond the specific context of Uasin Gishu County. Factors influencing access to primary healthcare services can vary significantly depending on geographical location, cultural norms, healthcare infrastructure, and other contextual factors. Therefore, the determinants identified in this study may not be applicable to capitated members in other regions of Kenya or in different counties; limiting the broader applicability of the research findings and the study also targeted NHIF accredited public health facilities in Uasin Gishu County, Kenya. Privately owned hospitals were excluded. Hence the study findings can be generalized to public facilities.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eNHIF capitated members are generally aware of their healthcare entitlement. However, efforts are needed to enhance more awareness regarding entitlement to surgical services, inclusion of dependents, access to information about the benefit package, feedback and complaint mechanisms, premium payment process, awareness of the premium to be paid, payment schedule, the waiting period before registration and accessing services, and penalties in the event of default. This\u0026nbsp;information\u0026nbsp;could be used to advocate for the implementation of effective communication systems that allow for real-time dissemination of information and feedback, as well as to conduct regular in-service\u0026nbsp;training\u0026nbsp;and recruiting a well-educated workforce that is familiar with NHIF procedures and terms in order to promote the NHIF in the face of capitated members\u0026apos; social-demographic profiles, and\u0026nbsp;to increase knowledge of the health coverage plan for the informal sector and flexible payment platforms. Utilizing vernacular to reach more communities, particularly in rural areas could broaden outreach.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from Kenya Methodist University Scientific and Ethics Review Committee (KeMU/SERC/HSM/22/2022), the National Commission of Science and Technology and Innovation (NACOSTI/P/22/19153), and the County Director of Health. Participants provided informed consent, assured of confidentiality and anonymity. They were informed of the voluntary nature of participation and their right to withdraw at any time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBarbara Nawire\u0026nbsp;Were\u0026nbsp;and Eunice\u0026nbsp;Muthoni Mwangi conceived the study. Barbara Nawire\u0026nbsp;Were, Eunice\u0026nbsp;Muthoni Mwangi and Lillian Wambui Muiruri\u0026nbsp;participated in the design, its implementation, and analysis. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ information\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors have been involved in health systems research activities in Kenya.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI\u0026nbsp;thank the county government of Uasin Gishu-County directors, the healthcare facility managers, service providers and their clients for their support in the study. I am also gratefully\u0026nbsp;to\u0026nbsp;my supervisors\u0026nbsp;Dr. Eunice Muthoni Mwangi and Ms. Lillian Wambui Muiruri\u0026nbsp;for their guidance through the process from inception to ensuring the objective of this study is achieved.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. The world health report: health systems financing: the path to universal coverage: executive summary. World Health Organization; 2010.\u003c/li\u003e\n\u003cli\u003eLiaropoulos L, Goranitis I. Health care financing and the sustainability of health systems. International Journal for Equity in Health. 2015 Dec; 14(1):1-4.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. An empirical model of access to health care, health care expenditure and impoverishment in Kenya: learning from past reforms and lessons for the future. World Health Organization; 2006.\u003c/li\u003e\n\u003cli\u003eHonda A. What is strategic purchasing for health? 2014.\u003c/li\u003e\n\u003cli\u003eLangenbrunner J, Cashin C, O\u0026apos;Dougherty S, editors. Designing and implementing health care provider payment systems: how-to manuals. World Bank Publications; 2009.\u003c/li\u003e\n\u003cli\u003eJames BC MD. The Case for Capitation [Internet]. Harvard Business Review. 2016. Available from: https://hbr.org/2016/07/the-case-for-capitation.\u003c/li\u003e\n\u003cli\u003eBusby M, Chapple L, Clover H, McCreanor J, Chapple I. Capitation care fee banding: aspects of reliability and validity of an online tool. British Dental Journal. 2018 Oct 26; 225(8):751-5.\u003c/li\u003e\n\u003cli\u003ePark M, Braun T, Carrin G, Evans DB, World Health Organization. Provider payments and cost-containment: lessons from OECD countries. World Health Organization; 2007.\u003c/li\u003e\n\u003cli\u003eFeldhaus I, Mathauer I. Effects of mixed provider payment systems and aligned cost sharing practices on expenditure growth management, efficiency, and equity: a structured review of the literature. BMC health services research. 2018 Dec; 18:1-4.\u003c/li\u003e\n\u003cli\u003eKoenecke A. A game theoretic setting of capitation versus fee-for-service payment systems. Plos one. 2019 Oct 7; 14(10):e0223672.\u003c/li\u003e\n\u003cli\u003eLagomarsino G, Garabrant A, Adyas A, Muga R, Otoo N. Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. The Lancet. 2012 Sep 8; 380(9845):933-43.\u003c/li\u003e\n\u003cli\u003eAbiiro GA, Alatinga KA, Yamey G. Why did Ghana\u0026rsquo;s national health insurance capitation payment model fall off the policy agenda? A regional level policy analysis. Health Policy and Planning. 2021 Jul 1; 36(6):869-80.\u003c/li\u003e\n\u003cli\u003eAlawode GO, Adewole DA. Assessment of the design and implementation challenges of the National Health Insurance Scheme in Nigeria: a qualitative study among sub-national level actors, healthcare and insurance providers. BMC Public Health. 2021 Dec; 21(1):1-2.\u003c/li\u003e\n\u003cli\u003eNyandekwe M, Nzayirambaho M, Kakoma JB. Universal health insurance in Rwanda: major challenges and solutions for financial sustainability case study of Rwanda community-based health insurance part I. Pan African Medical Journal. 2020 Sep 14; 37(1).\u003c/li\u003e\n\u003cli\u003eMunge K, Mulupi S, Barasa EW, Chuma J. A critical analysis of purchasing arrangements in Kenya: the case of the National Hospital Insurance Fund. International journal of health policy and management. 2018 Mar; 7(3):244.\u003c/li\u003e\n\u003cli\u003eObadha M, Chuma J, whongu J, Abiiro GA, Beck MJ, Barasa E. Preferences of healthcare providers for capitation payment in Kenya: a discrete choice experiment. Health Policy and Planning. 2020 Aug; 35(7):842-54.\u003c/li\u003e\n\u003cli\u003eObadha M, Chuma J, Kazungu J, Barasa E. Health care purchasing in Kenya: Experiences of health care providers with capitation and fee‐for‐service provider payment mechanisms. The International Journal of Health Planning and Management. 2019 Jan; 34(1):e917-33.\u003c/li\u003e\n\u003cli\u003eBarasa EW, Maina T, Ravishankar N. Assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in Kenya. International journal for equity in health. 2017 Dec; 16(1):1-4.\u003c/li\u003e\n\u003cli\u003eBarasa E, Nguhiu P, McIntyre D. Measuring progress towards sustainable development goal 3.8 on universal health coverage in Kenya. BMJ global health. 2018 Jun 1; 3(3):e000904.\u003c/li\u003e\n\u003cli\u003eEunice MM, Tenambergen W, Mapesa J, Mutai I. Citizen engagement in social health insurance purchasing, in selected counties in Kenya.\u003c/li\u003e\n\u003cli\u003eKrejcie RV, Morgan DW. Determining sample size for research activities. Educational and psychological measurement. 1970 Sep; 30(3):607-10.\u003c/li\u003e\n\u003cli\u003eSachs JD. Achieving universal health coverage in low-income settings. The Lancet. 2012 Sep 8; 380(9845):944-7.\u003c/li\u003e\n\u003cli\u003eXu W, Cai GJ, Li GN, Cao JJ, Shi QH, Bai J. Age or health status: which influences medical insurance enrollment greater? Journal of global health. 2016 Dec; 6(2).\u003c/li\u003e\n\u003cli\u003eMwaura GW, Kamano JH, Mwangi AW, Lusimbo L, Mugo R, Too K, Andale T, Itsura P, Kibachio J, Gathecha G, Aruasa W. Awareness, Uptake and factors associated with NHIF uptake in Western Kenya: A case of 4 counties-Busia, Trans Nzoia, Vihiga and Siaya.\u003c/li\u003e\n\u003cli\u003eChuma J, Maina T. Catastrophic health care spending and impoverishment in Kenya. BMC health services research. 2012 Dec; 12(1):1-9.\u003c/li\u003e\n\u003cli\u003eSalari P, Di Giorgio L, Ilinca S, Chuma J. The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ global health. 2019 Nov 1;4(6):e001809.\u003c/li\u003e\n\u003cli\u003eNjagi P, Arsenijevic J, Groot W. Decomposition of changes in socioeconomic inequalities in catastrophic health expenditure in Kenya. PLoS One. 2020 Dec 29; 15(12):e0244428.\u003c/li\u003e\n\u003cli\u003eNyman JA. The theory of demand for health insurance. Stanford University Press; 2003.\u003c/li\u003e\n\u003cli\u003eExplanation of the benefit package for the National Scheme [Internet]. 2015. Available from: http://publications.universalhealth2030.org/uploads/nhif_benefits_package.pdf\u003c/li\u003e\n\u003cli\u003eOngiri IS, Kubani JA. Unions demand talks on NHIF rates. Daily Nation. 2015:17.\u003c/li\u003e\n\u003cli\u003eMulupi S, Kirigia D, Chuma J. Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya. BMC health services research. 2013 Dec; 13(1):1-2.\u003c/li\u003e\n\u003cli\u003eMbau R, Kabia E, Honda A, Hanson K, Barasa E. Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya. International journal for equity in health. 2020 Dec; 19:1-8.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. (2008). Health System Financing. Retrieved from https://www.who.int/healthinfo/statistics/toolkit_hss/EN_PDF_Toolkit_HSS_Financing.pdf\u003c/li\u003e\n\u003cli\u003eKironji KM, Tenambergen WM, Mwangi EM. Effects of Perceived Image of NHIF Outpatient Facilities on Utilization of Primary Care Services by Private University Employees in Nairobi County.\u003c/li\u003e\n\u003cli\u003eOchieng DL. \u003cem\u003eFactors influencing uptake of national hospital insurance fund cover by rural households in Kasipul division, Rachuonyo south sub county, Homa Bay County\u003c/em\u003e (Doctoral dissertation, University of Nairobi).\u003c/li\u003e\n\u003cli\u003eOtieno PO, Wambiya EO, Mohamed SM, Mutua MK, Kibe PM, Mwangi B, Donfouet HP. Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya. BMC Public Health. 2020 Dec; 20:1-9.\u003c/li\u003e\n\u003cli\u003ePauly MV. The economics of moral hazard: comment. The american economic review. 1968 Jun 1; 58(3):531-7.\u003c/li\u003e\n\u003cli\u003eClark T, Foster L, Bryman A, Sloan L. Bryman\u0026apos;s social research methods. Oxford University Press; 2021.\u003c/li\u003e\n\u003cli\u003eOrangi S, Kairu A, Malla L, Ondera J, Mbuthia B, Ravishankar N, Barasa E. Impact of free maternity policies in Kenya: an interrupted time-series analysis. BMJ Global Health. 2021 Jun 1; 6(6):e003649.\u003c/li\u003e\n\u003cli\u003eJowett M. Theoretical insights into the development of health insurance in low-income countries. 2004 Mar.\u003c/li\u003e\n\u003cli\u003eIlinca S, Di Giorgio L, Salari P, Chuma J. Socio-economic inequality and inequity in use of health care services in Kenya: evidence from the fourth Kenya household health expenditure and utilization survey. International journal for equity in health. 2019 Dec; 18:1-3.\u003c/li\u003e\n\u003cli\u003eSuchman L. Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study. International journal for equity in health. 2018 Dec; 17:1-8.\u003c/li\u003e\n\u003cli\u003eSieverding M, Onyango C, Suchman L. Private healthcare provider experiences with social health insurance schemes: findings from a qualitative study in Ghana and Kenya. PLoS One. 2018 Feb 22; 13(2):e0192973.\u003c/li\u003e\n\u003cli\u003eEinav L, Finkelstein A. Moral hazard in health insurance: what we know and how we know it. Journal of the European Economic Association. 2018 Aug 1; 16(4):957-82.\u003c/li\u003e\n\u003cli\u003eRono GJ. Out-Of-Pocket Payment for Healthcare and Its Effects on Household Welfare in Rural and Urban Areas of Kenya [Internet]. 2017. Available from: https://ir-library.ku.ac.ke/handle/123456789/17969\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. World Health Organization; 2010.\u003c/li\u003e\n\u003cli\u003eMorris S, Devlin N, Parkin D, Spencer A. Health insurance and healthcare financing. Economic Analysis in Health Care. Chichester: John Wiley and Sons Ltd. 2007:149-82.\u003c/li\u003e\n\u003cli\u003eKNBS K. Kenya Population and Housing Census Volume I: Population by County and Sub-County. Vol. I. 2019; 2019.\u003c/li\u003e\n\u003cli\u003eMugenda OM, Mugenda AG. Research methods: Quantitative \u0026amp; qualitative approaches. Nairobi: Acts press; 2003.\u003c/li\u003e\n\u003cli\u003eChuma J, Maina T. Catastrophic health care spending and impoverishment in Kenya. BMC Health Serv Res. 2012;12(1):1\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eKituku AM, Amata E, Wachira M. Determinants of the uptake of NHIF medical cover by informal sector workers: A case of UNAITAS SACCO members in Muranga County. 2016; \u003c/li\u003e\n\u003cli\u003eNdungu TT. Factors influencing uptake of national health insurance in the informal sector: a case of ithanga division in murang\u0026rsquo;a county, Kenya. University of Nairobi; 2015. \u003c/li\u003e\n\u003cli\u003eMwangi EM, Tenambergen W, Mapesa J, Mutai I. Citizen engagement in social health insurance purchasing, in selected counties in Kenya. Int J Community Med Public Heal. 2019;6(10):4145\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eNamuhisa JA. Determinants of uptake of National Hospital Insurance Fund scheme by the informal sector in Nairobi county, Kenya. Unpubl MBA Proj Kenyatta Univ Kenya. 2014\u003c/li\u003e\n\u003cli\u003eGuy Carrin, Chris James, Key Performance Indicators for the Implementation of Social Health Insurance, Applied Health Economics and Health Policy, 10.2165/00148365-200504010-00004, \u003cstrong\u003e4\u003c/strong\u003e, 1, (15-22), (2005).\u003cem\u003e\u003c/em\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Capitation, National Hospital Insurance Fund, Universal Health Coverage, ","lastPublishedDoi":"10.21203/rs.3.rs-3949354/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3949354/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study identifies provision of primary healthcare services using the capitated health model as a prerequisite for promoting positive healthcare outcomes for a country’s population. However, capitated members have continued to face challenges in accessing primary healthcare services despite enrolment in the National Health Insurance Fund (NHIF). This study sought to determine if variables such as patient knowledge of the NHIF benefit package, NHIF Premium Payment processes, selecting NHIF capitated health facilities, and NHIF Communication to citizens’ influences access to primary healthcare services.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional analytical research design was adopted. Data was collected from patients who were using NHIF cards, who were drawn from health facilities. Data was collected using a structured questionnaire where some of the questions were rated using the Likert scale to enable the generation of descriptive statistics. Data was analysed using descriptive and inferential statistics which was conducted with the aid of SPSS version 25. Bivariate analysis was conducted utilizing Chi-square to facilitate the comparison of the independent and the dependent variables. Data was presented in tabular formats where each of the specific objectives was used as parameters of interest to the study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study found that four independent variables (Patient knowledge of NHIF Benefit Package, NHIF Premium Payment processes, Selecting NHIF capitated Health Facility, and NHIF Communication to citizens) were significant predictors of access to capitated healthcare\u003c/p\u003e\n\u003cp\u003eservices with significance values of .001, .001, .001 and .001 respectively at 95% significance level.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study found that familiarity with the NHIF benefit package significantly influenced NHIF capitated members' access to primary healthcare services in Uasin Gishu County. While most members were aware of their healthcare entitlements, there's a need for increased awareness regarding access to surgical services and dependents' inclusion. Facility selection also played a crucial role, influenced by factors like freedom of choice, NHIF facility selection rules, facility appearance, and proximity to members' homes. NHIF communication positively impacted access, with effective communication channels aiding service accessibility. Premium payment processes also significantly linked with service access, influenced by factors such as payment procedures, premium awareness, payment schedules, registration waiting periods, and penalties for defaults. Overall, patient knowledge, NHIF communication, premium payment processes, and facility selection all contributed positively to NHIF capitated members' access to primary healthcare services in Uasin Gishu County.\u003c/p\u003e","manuscriptTitle":"Determinants of Primary Healthcare Services Access by National Health Insurance Fund Capitated Members in Uasin Gishu County, Kenya","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-10 18:33:59","doi":"10.21203/rs.3.rs-3949354/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-11T13:42:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-06T01:32:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-06T01:32:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-02-11T20:30:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4d7cb624-f795-4b1e-b6d5-cdb1665c202b","owner":[],"postedDate":"April 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-09T16:17:22+00:00","versionOfRecord":{"articleIdentity":"rs-3949354","link":"https://doi.org/10.1186/s12913-024-11282-8","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2024-09-04 16:08:20","publishedOnDateReadable":"September 4th, 2024"},"versionCreatedAt":"2024-04-10 18:33:59","video":"","vorDoi":"10.1186/s12913-024-11282-8","vorDoiUrl":"https://doi.org/10.1186/s12913-024-11282-8","workflowStages":[]},"version":"v1","identity":"rs-3949354","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3949354","identity":"rs-3949354","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}