Even as health facilities get closer, transportation remains a barrier to care

By John Mwangi and Joyce Nema

Kenya has been making strides in bringing health facilities closer to people. Public health facilities increased from 3,512 in 2003 to 13,576 in 2021. By 2021, 90% of Kenyans lived within one hour of a health facility. However, for many patients, transportation remains a major barrier to care because the nearest facility cannot provide the care they need.

As field researchers in the Kenya Healthcare Financial Diaries, we have seen this firsthand. Being unable to easily access specific kinds of care at nearby facilities, members of the households we study are delaying care, missing appointments, and incurring enormous costs in time and money to try and get the care they need. Sometimes the consequences are severe.

Some with chronic illnesses struggle to keep up with ongoing care far from home

A number of respondents with chronic conditions like hypertension and diabetes are not being served by their local dispensaries. Instead, they need to travel for specialized clinics for their checkups and medication.

In Rural Kwale, “Khalim” is living with hypertension and recovering from a stroke. He was first diagnosed with hypertension in 2018 and initially sought care at a Level 4 sub-county hospital. Due to the need for consistent medical care, he even relocated to near the hospital. While there, he had a stroke and received care. But, unable to work after the stroke, he eventually returned to his rural home where he could stay with his son.

Currently, he travels from the rural home to the sub-county hospital every month. Each journey costs KSh 700 and takes around three hours each way. Since he is unable to travel alone, his son has to accompany him each time. That means spending KSh 2800 per month just on the transportation. With a typical income of around KSh 14,000, this means the family is effectively incurring catastrophic health expenditure (20%) every month.

Sometimes Khalim’s family can’t come up with that much money, and they delay visits to the hospital. Other times, road conditions and weather complicate travel. When it rains, the partially collapsed bridge connecting the community to the main road is impassable. Khalim and his son either skip the trip or have to use an alternative route that takes more than four hours and comes with an extra cost. Khalim can’t transfer his care to the local health centre because they don’t have the personnel and equipment needed.

Another respondent, “Ziya,” in a town in Isiolo County suffers from Type 1 diabetes. Every two weeks, she is supposed to travel to another town, about two hours away, at KSh 2000 round trip, for a checkup and to collect her insulin injection pens. Due to lack of refrigeration, she cannot take more supply on each visit. The local Level 4 hospital does not treat diabetes patients.

Ziya has a newborn at home and is not working. Her husband has a regular job, but only makes KSh 10,000 per month, and even that is often paid late. The couple cannot spend so much of their income every month on these visits, so they don’t. Ziya tries to find someone coming from the other town to bring her insulin. Sometimes she has to go without, and she tries to manage on her own by dosing herself with sugar water.

Transport can be a problem even in dense urban areas

We assumed that transportation barriers primarily affected rural communities, where individuals must travel long distances on poor roads to reach health facilities. While the challenges in these rural locations are severe, we have also seen that the challenge persists in urban settings. In Nairobi’s informal settlements, for example, transport costs also inhibit care.

“Charity” lives in an informal settlement with her husband and four children. Her husband does mjengo (construction) casual jobs, and Charity herself earns an income from small casual jobs like fetching water, washing clothes, and cleaning homes. A few years ago, the family moved from an iron sheet house that cost KSh 2000 per month to their current brick flat that costs KSh 5100 per month in hopes that the cleaner, drier environment would reduce the frequent illnesses Charity and her youngest daughter were facing. But now, covering rent is a stretch. Her husband’s income needs to be retained for rent, while nearly all of what Charity earns—usually less than KSh 200 per day—goes towards food.

When Charity delivered her second born eight years ago, she developed deep vein thrombosis (DVT). Since we met her in August, the veins in her leg have been swelling painfully when she stands and walks. The pain goes up to her abdomen. She had one year of Social Health Insurance Fund (SHIF) premiums paid by a non-governmental organisation, which motivated her to seek medical assistance to sort out the issue. But doctor after doctor at local facilities have told her they can’t determine whether she is suffering from dangerous DVT symptoms or has harmless varicose veins. Some have suggested she may also have a hernia requiring surgery. She needs a specialised scan at either Kenyatta National Hospital (main public national hospital) or Mbagathi Hospital (a level 5 hospital). Scans, they said, are not covered by SHIF, so she needs to look for the money before she plans a visit. She thinks she needs at least KSh 5000, though she doesn’t know the exact price yet.

The lack of a diagnosis has now interrupted her family planning method. Without a clear diagnosis, the local health centre insisted on halting her contraceptive injections. If she does have DVT, the injections could be high risk. They told her she can only be on the non-hormonal coil, which is only available at Mbagathi or Kenyatta National hospitals. Without a few hundred shillings for transport, she hasn’t yet gone. She’s been without birth control for a few months now. She says her husband doesn’t understand and won’t use condoms. When her period was late last month, she was wrecked with anxiety. “If I’m pregnant, I don’t know what I will do. We cannot have another child.”

What can be done?

What does this mean for Kenya’s health system? Kenya has been building a system of primary healthcare with referrals leading up to higher level facilities when needs can’t be met locally. But if patients cannot use those referrals, care needs remain unmet.

Unmet needs can cause further burdens on front line facilities and worsen health outcomes. Charity, for example, has visited her nearest health centre nine times and a private hospital once all in the last five months. She keeps following up on the same issues, out of both fear that something terrible may happen and hope that the medical staff might eventually help.

Some counties are trying new approaches to address this challenge. In Murang’a, for example, some respondents are receiving hypertension follow up care through telemedicine. Patients arrive at the health centre for regularly scheduled visits and talk to a doctor on the computer. While they feel the loss of not receiving physical examinations, it keeps costs down and makes it easier to keep up with regular visits.

Perhaps Murang’a is onto something. To ease the cost burden for ordinary families, we need to figure out ways to get care -not just clinics- closer to communities.