Removing user fees in Kenya’s public health facilities was meant to expand access and reduce inequality. But while usage of outpatient and maternal health services did increase, persistent challenges such as informal charges, supply shortages, and staff constraints have undermined the policy’s impact. Strengthening health systems alongside financial reforms is essential for sustainable progress.
In 2013, Kenya abolished user fees at public health centers and dispensaries and introduced free maternity services nationwide. The policy was designed to eliminate a key barrier to healthcare access for millions of people, many of whom live below the poverty line. Prior to this, even small fees for registration, drugs, or diagnostic services often deterred patients from seeking care.
The reform followed decades of shifting approaches to health financing. User fees were first introduced in the late 1980s under pressure from international financial institutions, which encouraged African governments to raise revenue through cost-sharing. While intended to improve sustainability, the policy backfired: usage of health services plummeted, with poorer households the most affected. Studies across the region showed that children’s visits to health facilities fell sharply, and maternal mortality rose as women avoided facilities they could not afford.
Kenya was not alone in reversing course. Uganda eliminated user fees in 2001, leading to a dramatic increase in outpatient visits but also exposing the health system to new strains. Ghana and South Africa also adopted partial fee exemptions for specific groups, such as pregnant women and children. Kenya’s 2013 reforms marked one of the most ambitious attempts in East Africa to combine universal exemptions with targeted programs such as free maternity care.
Equity, efficiency, and persistent disparities
Removing user fees in Kenya’s public health facilities led to clear and immediate benefits. The use of both outpatient and maternal health services increased sharply, with children under five and adults from low-income households showing the largest gains. In urban areas, poor women were more likely to give birth in public health facilities, contributing to a decline in maternal deaths and higher rates of skilled birth attendance. These results demonstrate that removing financial barriers can improve access for marginalized populations.
However, these equity gains were uneven and, in many cases, fragile. Many rural facilities continued informal charging because government reimbursements were either delayed or insufficient, and high patient volumes compounded shortages of essential drugs and basic medical supplies. Patients were also often forced to buy medicines from private pharmacies at higher prices, undermining the financial protection the policy sought to provide. For people living in remote or arid regions, geographical barriers, poor infrastructure, and limited transport options continued to restrict access, while cultural and informational barriers further prevented some communities from fully benefiting.
The persistence of these non-financial barriers also exacerbated existing inequalities. People with greater financial means continued to access higher-quality services in private or well-resourced facilities, creating a two-tier system in which the poor relied on overstretched public services. Free healthcare on paper does not automatically translate into equitable health outcomes in practice.
Efficiency challenges further complicate the picture. Government reimbursements frequently lagged behind costs, forcing facilities to operate with constrained resources. Some resorted to informal charges or redirected patients to private providers, which sometimes increased out-of-pocket spending. This dual reality—care that was technically free but practically costly— diminished the intended economic protection for households, particularly among the most vulnerable parts of the population.
At the same time, removing user fees increased demand for services, particularly preventive and maternal care. Antenatal visits and diagnostic testing rose, demonstrating the potential for long-term improvements in health outcomes. Even so, the surge in patient volume placed significant strain on health facilities. Health workers reported higher workloads, occasionally compromising service quality, while drug stock-outs became more frequent. The combined effect was mixed: access expanded, but quality and consistency varied widely across regions and facilities, reinforcing rather than eliminating disparities in health outcomes.
The way forward
Kenya’s experience demonstrates that removing user fees can boost access, but it is not sufficient on its own to achieve equitable health outcomes. Sustainable progress requires combining financial reforms with investments that strengthen the health system and address operational challenges.
Uganda’s experience following the 2001 abolition of user fees provides another clear illustration. To prevent financial disruption at health facilities, the government quickly released funds for drug procurement and increased the national health budget to replace lost revenue. Primary healthcare grants were expanded, while new financial management guidelines improved flexibility and accountability. Health worker salaries were raised significantly, helping to boost morale, retain staff, and reduce informal charging. Ugandan policymakers also reorganized the country’s drug supply system and benefited from a shift in international aid from project-based to sector-wide support, ensuring consistent financing for facilities and uninterrupted service delivery.
As another example, Burkina Faso faced major challenges after introducing free healthcare for maternal and child services in 2016, including widespread stock-outs of essential medicines and delayed reimbursements to facilities. In response, the government established the Health Financing Fund to ensure predictable and timely funding flows, while reforming the supply chain gave facilities greater flexibility to procure medicines locally when central stores were depleted. The government also introduced independent monitoring mechanisms and increased health budget allocations to sustain the Gratuité policy (user fee exemption policy). These steps strengthened the capacity of the health system and embedded the policy within the broader Universal Health Coverage framework.
Supporting and motivating health workers is another critical dimension. Burundi provides an illustrative example: the Performance-Based Financing (PBF) program, introduced alongside the removal of user fees in 2006, linked financial incentives to measurable service outputs. Initially piloted in three provinces, the government scaled the program nationally in 2010, covering public and most non-profit facilities. PBF improved the quality of maternal and outpatient services, attracted qualified staff to underserved areas, and helped stabilize facility operations. Although equity gaps persisted, PBF demonstrated the value of integrating performance incentives to maintain service delivery while free healthcare policies expand access.
Taken together, these experiences underscore that Kenya’s path to equitable and sustainable free healthcare depends on aligning financial reforms with robust system-wide measures. Ensuring timely and adequate funding, reliable supply chains, motivated and well-supported staff, and transparent performance management will enable Kenya not only to expand access but also to deliver quality care that reaches the whole population, including those most in need.
