DESK REVIEWS | 02.02.03. Out-of-pocket expenditure

DESK REVIEW | 02.02.03. Out-of-pocket expenditure

In 2017/2018, 49% of the current health expenditure was covered by the Government, 34% by household out-of-pocket payments, and 16% by payment via privately purchased insurance schemes and employer-based insurance schemes. High out-of-pocket expenses indicate a potentially catastrophic impact of ill health on family incomes in Hong Kong (Food and Health Bureau, 2019b).


AD MediLink. (2019). How Much Do Private Hospitals Charge in Hong Kong?

Food and Health Bureau. (2019b). ESTIMATES OF HEALTH EXPENDITURE.

Hospital Authority. (2020b). Fees and Charges.

In 2004 Kenya adopted a uniform user fee policy “the 10/20” policy to generate revenue at the lower-level facilities. Standardized fees were set at a flat rate of 10 Kenya shillings in dispensaries (table 2) and 10 Kenya shillings in health centres (table 2). Any fees are waived for people requiring treatment for malaria, tuberculosis, and sexually transmitted diseases, for children under 5 years old, for births and antenatal care (ANC) services and for people from poor households. However, clear guidelines on laboratory fees inclusion and criteria to identify patients from poor households were missing from the policy.

As a result, adherence to this policy was minimal with:

  • patients paying for services at private shops that could have been free (but may not have been available at the facility)
  • health facilities loading expenses associated with free services on other non-free services
  • patients paying more than the specified amount due to:
    1. the facilities’ need for revenue
    2. the lack of strategies to compensate facilities for lost revenue or lack of awareness of the policy (Onsomu et al., 2014; Opwora et al., 2015).

It is estimated that out of pocket expense contribute to 26.1% out of the total health expenditure (World Health Organization, 2017b). In 2018, about  7% of households in Kenya faced catastrophic expenditures due to OOP payments (Salari et al., 2019). Furthermore,  75% of the population is not covered under any health insurance and typically relies on out of pocket expenses to cover the cost of care (Kenya Healthcare Federation and Task Force Health Care, 2016). However, it is the goal of the UHC, currently under trial, to tackle the high out-of-pocket costs by ensuring that citizens can access good quality and affordable (without paying out of their own pockets) basic health services (Wangia & Kandie, 2018).


Kenya Healthcare Federation and Task Force Health Care. (2016). Kenyan Healthcare Sector: Opportunities for the Dutch Life Sciences & Health Sector. Nairobi, Kenya.

Onsomu, D., Muthaka, G., Mwabu, O., Nyanjom, A., Dutta, T. M., Maina, C. B., & Muchir, S. (2014). Public Expenditure Tracking Survey in Kenya, 2012 (PETS-Plus). Washington, DC.

Opwora, A., Waweru, E., Toda, M., Noor, A., Edwards, T., Fegan, G., … Goodman, C. (2015). Implementation of patient charges at primary care facilities in Kenya: implications of low adherence to user fee policy for users and facility revenue. Health Policy and Planning, 30(4), 508–517.

Salari, P., Di Giorgio, L., Ilinca, S., & Chuma, J. (2019). The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ Global Health, 4(6).

Wangia, E., & Kandie, C. (2018). Policy brief: Refocusing on quality of care and increasing demand for services; Essential elements in attaining universal health coverage in Kenya. Nairobi, Kenya.

World Health Organization. (2017b). Primary Health Care Systems (PRIMASYS): Case Study from Kenya, abridged version. Geneva.