Mu ii hi, Moses Kinyanjui; Oleche, Ma ine Odhiambo; Kia ie, F ancis; Mwangi,
Tabi ha
A icle
Heal hca e inancing ulne abili y and se ice u iliza ion
in kenya du ing he co id-19 pandemic, wi h a ocus on
policies o p o ec human capi al
Economies
P o ided in Coope a ion wi h:
MDPI – Mul idisciplina y Digi al Publishing Ins i u e, Basel
Sugges ed Ci a ion: Mu ii hi, Moses Kinyanjui; Oleche, Ma ine Odhiambo; Kia ie, F ancis; Mwangi,
Tabi ha (2025) : Heal hca e inancing ulne abili y and se ice u iliza ion in kenya du ing he
co id-19 pandemic, wi h a ocus on policies o p o ec human capi al, Economies, ISSN 2227-7099,
MDPI, Basel, Vol. 13, Iss. 8, pp. 1-18,
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Ci a ion: Mu ii hi, M., Oleche, M.,
Kia ie, F., & Mwangi, T. (2025).
Heal hca e Financing Vulne abili y
and Se ice U iliza ion in Kenya
Du ing he COVID-19 Pandemic, wi h
a Focus on Policies o P o ec Human
Capi al. Economies,13(8), 242.
h ps://doi.o g/10.3390/
economies13080242
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licenses/by/4.0/).
A icle
Heal hca e Financing Vulne abili y and Se ice U iliza ion
in Kenya Du ing he COVID-19 Pandemic, wi h a Focus
on Policies o P o ec Human Capi al
Moses Mu ii hi 1,* , Ma ine Oleche 1, F ancis Kia ie 2and Tabi ha Mwangi 3
1
Depa men o Economics and De elopmen S udies, Uni e si y o Nai obi, Nai obi P.O. Box 30197-00100, Kenya;
[email p o ec ed]
2Depa men o Managemen Science, Kenya a Uni e si y, Nai obi P.O. Box 43844-00100, Kenya;
[email p o ec ed]
3Mac oeconomic Depa men , Kenya Na ional Bu eau o S a is ics (KNBS), Nai obi P.O. Box 30266-00100, Kenya;
[email p o ec ed]
*Co espondence: [email p o ec ed]
Abs ac
The analysis o household heal h inancing ulne abili y and i s impac on heal h se ice
u iliza ion du ing he COVID-19 pandemic emains inadequa ely explo ed in Kenya. This
s udy was designed o examine he impac o heal h inancing ulne abili y on heal h
se ices u iliza ion du ing he COVID-19 pe iod. A heal h inancing ulne abili y index
(HFVI) was cons uc ed o assess he inancial isk ha indi iduals aced in accessing
essen ial heal h se ices. A pooled panel p obi model was es ima ed o measu e he e ec
o HFVI on se ice up ake. The s udy ound a signi ican nega i e associa ion be ween
HFVI and heal h se ice u iliza ion, indica ing ha a high le el o heal h inancing ulne a-
bili y is linked o poo heal h in pe iods o eme gencies. To add ess his issue, he s udy
ecommends implemen a ion o mul iple policy measu es du ing c isis pe iods, including
enhancing social heal h insu ance, p o iding inancial suppo o ulne able households,
and inc easing public expendi u e on p ima y heal hca e sys ems ac oss coun ies, especially
on d ugs, e e al logis ics, pe sonnel, medical equipmen , and diagnos ic echnologies.
Keywo ds: heal h inancing ulne abili y index; heal hca e; heal h se ice u iliza ion;
coun ies; heal h insu ance; COVID-19; human capi al; Kenya
1. In oduc ion
1.1. Backg ound
Heal hca e in Kenya is p o ided h ough public, p i a e- o -p o i , and p i a e no - o -
p o i acili ies. Heal hca e se ices a e a anged in ie s unning om le el 1 (dispensa y,
he lowes le el o ca e) o le el 6 ( e e al hospi als, he highes le el o ca e). Public
heal h acili ies a e ound in he lowe le els o ca e, while p i a e o -p o i acili ies a e
concen a ed in he highe le els o ca e (Minis y o Heal h e al.,2005).
In he yea s since independence in 1963, he heal h inancing landscape has been
oscilla ing om a ee o a use -cha ge sys em (Chuma & Okungu,2011;Wamai,2009;
Chuma e al.,2009;Mwabu e al.,1995). Cu en ly, heal hca e in Kenya is inanced om
h ee main sou ces: ou -o -pocke cha ges, ax e enues, and dono unds. In 2005–06,
ou -o -pocke paymen s (OOP) we e 29.1% o o al heal h expendi u e (Minis y o Medical
Se ices & Minis y o Public Heal h and Sani a ion,2009b). La ge ou -o -pocke paymen s
Economies 2025,13, 242 h ps://doi.o g/10.3390/economies13080242
Economies 2025,13, 242 2 o 18
can be a ba ie o sus ainable heal hca e because o e ime, hey make indi iduals ulne able
o po e y, o us a e he exi om po e y (Ogwang & Mwabu,2025). A su ey pe o med
in 2007 showed ha 38% o people who we e ill ci ed a lack o money as a ba ie o seeking
heal hca e (Minis y o Medical Se ices & Minis y o Public Heal h and Sani a ion,2009a).
By 2009–10, ou -o -pocke paymen s s ill made up nea ly a qua e o o al heal h expendi u e.
The ad e se impac o use ees on heal hca e u iliza ion in Kenya was b ough o ligh when
ees o ma e ni y se ices a dispensa ies and heal h cen e s we e abolished (Le ie,2013),
esul ing in a massi e in lux o pa ien s o hese acili ies (S acey e al.,2021).
B ie ly, Kenya’s heal h sys em is inanced h ough ou main sou ces: go e nmen
e enue, ou -o -pocke cha ges, o eign assis ance, and p i a e sec o con ibu ions, es i-
ma ed, espec i ely, a 45.98%, 24.3%, 18.51%, and 35.51% o he o al heal h expendi u e
(Minis y o Heal h,2021).
Figu e 1p o ides he end o he Kenyan go e nmen budge a y alloca ions o he
heal h sec o o he pe iod 2012–21.
Figu e 1. Heal h Expendi u e (pe cen o o al go e nmen budge . Sou ce: Go e nmen Budge a y
Alloca ions) (Republic o Kenya,2012–2023).
1.2. Resea ch P oblem
The se iousness o he heal hca e inancing gap in Kenya was e ealed by he ad en
o he COVID-19 pandemic in 2019–22, which ound he coun y unp epa ed o he sudden
heal h needs o he popula ion. The pandemic p ecipi a ed dis ess in bo h u ban and u al
heal h acili ies, as hese uni s did no ha e he capaci y o ca e o pa ien s, especially hose
wi h COVID-19 symp oms (Pu o & Kelly,2021). The si ua ion o ced he Go e nmen o
ealloca e, in a o o COVID-19 eme gencies, sca ce heal h esou ces al eady commi ed
o ackling exis ing heal h condi ions such as HIV, TB, Mala ia, and childhood diseases
(Ba asa e al.,2021).
Du ing he COVID-19 pandemic, u iliza ion o heal hca e se ices in heal h acili ies
egis e ed a signi ican d op in p ac ically all 47 Kenyan coun ies (Wambua e al.,2022).
Fo example, he e we e subs an ial declines in clinic a endance du ing he mon h o
Ap il 2020. In pa icula , d ops in isi s we e obse ed o all unde - and o e - i e child en,
o inal an ena al ca e, o hype ension and diabe es, and o pe sons needing HIV es ing.
The ac o s associa ed wi h he declines in isi s included (i) he ea o con ac -
ing he a ious a ian s o he COVID-19 disease, (ii) inabili y o access heal hca e se -
ices due o lack o income, and (iii) wai ing ime due o la ge c owds a heal h acili ies
Economies 2025,13, 242 3 o 18
(Wambua e al.,2022). Vulne abili y o a lack o ca e o any illness du ing he COVID-19
pe iod was compounded by he policies unde aken by he go e nmen o con ain he
pandemic. The con ainmen measu es included imposi ion o s ic cu ews—lockdown o
schools, businesses, and ma ke places, banning o in e na ional ligh s, local a el, and o
la ge social ga he ings, among o he s (Ondi i e al.,2020).
The lockdowns caused a ied economic consequences, such as job loss, ood and
housing insecu i y, u he agg a a ing he heal h c isis (Ondi i e al.,2020). Thus, i
is no su p ising ha du ing he COVID-19 pandemic, u iliza ion o heal hca e se ices
a bo h public and p i a e acili ies signi ican ly wen down. Howe e , he ex en o
which he d op in heal hca e u iliza ion is linked o households’ economic ulne abili y
associa ed wi h he pandemic has no hi he o been in es iga ed. An impo an ace o
his s udy was o e alua e he e ec o household heal hca e inancing ulne abili y on he
u iliza ion o heal hca e du ing he COVID-19 pe iod. A ela ed objec i e was o use he
e idence gene a ed o sugges policies o p o ec human capi al, pa icula ly heal h capi al,
in con ex s o disease pandemics and eme gencies.
2. Rela ed Li e a u e
Ini ial s udies o he e ec o COVID-19 on u iliza ion o heal h se ices showed
widesp ead educ ions (Riley e al.,2020), as seen in p e ious epidemics in Sub-Saha an
A ica (Ba den-O’Fallon e al.,2015;Bolkan e al.,2018;B olin Ribacke e al.,2016;
Els on e al.,2016;Takahashi,2015). Wha is also no able om p e ious s udies is
ha some popula ion g oups a e a g ea e isk o being se e ely a ec ed du ing pe i-
ods o disease ou b eaks, pa icula ly child en, women, and pe sons in ex eme po e y
(Ba den-O’Fallon e al.,2015).
In Kenya and Uganda, he e is e idence ha COVID-19 caused mo e han wo- hi ds o
households o expe ience ad e se income shocks, hus educing hei abili y o a o d ood
and heal h se ices (Kansiime e al.,2020). This e idence inds suppo in Kang e al. (2023)
in Chad, who ound ha wo- hi ds o households, bo h u al and u ban, epo ed income
educ ions, wi h u ban a eas being hi ha des in 2020, and he u al a eas su e ing simila ly
in 2021. Solymá i e al. (2022) shows ha COVID-19 was associa ed wi h la ge educ ions
in heal h se ice u iliza ion, pa icula ly in slum a eas. This s udy is closes o ha o
Janssens e al. (2021), ega ding he nega i e e ec o COVID-19 on heal hca e up ake
among low-income households. Janssens e al. ound ha 80 pe cen o hei sample had
expe ienced income loss du ing he COVID-19 pe iod. Edeh e al. (2025) show ha COVID-
19 educed ca as ophic heal h expendi u e in Nige ia, since, a guably, legal es ic ions
limi ed access o medical se ices, hus educing ou -o -pocke expendi u e. This inding
was in con as o Jung e al. (2021), who ound ha he loss o household income c ea ed
an economic bu den, hus inc easing ca as ophic heal hca e spending.
B uce e al. (2022) epo inancial ha dships among Ame ican households compounded
by wo ies ha COVID-19 was agg a a ed by exis ing heal h condi ions and co-mo bidi ies.
The s udy ound ha he households ha we e inancially cons ained o seek heal hca e
p e-COVID-19 we e he mos a ec ed by illnesses con ac ed du ing he pandemic pe iod,
while hose in he middle class we e neu ally a ec ed, wi h some escaping he angs o he
pandemic. The indings o his s udy p o ided he S a e Go e nmen s in he Uni ed S a es
wi h he e idence hey needed o a ge help o ulne able households, he eby educing he
isk o losing human capi al and li elihoods. Simila ly, e o s should be made in A ica o
p o ide such e idence and u he encou age i s use in con ex s o disease epidemics.
Many s udies in low- and middle-income coun ies epo nega i e associa ions be ween
COVID-19 and heal h se ice u iliza ion. See, e.g., Wambua e al. (2022), Siedne e al. (2020),
Economies 2025,13, 242 4 o 18
Ba asa e al. (2021), Ha egeka e al. (2021), Bu e al. (2021), Do wa d e al. (2021),
Adelekan e al. (2020), Wong e al. (2021), and Za e al. (2020).
In Kenya, Macha ia e al. (2020) c ea ed COVID-19 ulne abili y indices o iden i y
Kenyan households who we e a isk o no accessing heal hca e du ing he pandemic. The
au ho s cons uc ed h ee indices spanning 295 sub-coun ies in he coun y. The indices
included he Social Vulne abili y Index (SVI), Epidemiological Vulne abili y Index (EVI), and
a Social Epidemiological Vulne abili y Index (SEVI). The esul s ound ha 49 sub-coun ies
in he no h-wes e n and eas e n pa s o Kenya had app oxima ely 6.9 million ulne able
people, wi h only 58 sub-coun ies wi h 9.7 million people (ou o a popula ion o abou
52 million) who we e unlikely o be a ec ed by he pandemic. These indices demons a ed
coun y-le el he e ogenei ies in wel a e ulne abili ies occasioned by COVID-19. Howe e ,
Macha ia e al. (2020) did no analyze how he pandemic a ec ed households’ abili y o
pay o heal hca e. In pa icula , he link be ween heal h se ice u iliza ion and households’
inancial ulne abili y, esul ing om he COVID-19 pandemic, was no in es iga ed.
Households’ capaci y o pay o heal hca e was a isk o being e oded by COVID-19 i sel
and by he measu es o con ain i .
Speci ic s udies in A ica e alua ing he impac o lockdown measu es o igh
COVID-19 in Sou h A ica de ec ed a subs an ial d op in p ima y heal hca e u iliza ion
(Adelekan e al.,2020;Siedne e al.,2020). In Kinshasa, Democ a ic Republic o Congo,
signi ican d ops in usage o essen ial heal h se ices we e expe ienced ollowing he adop-
ion o public heal h measu es agains COVID-19 (Ha egeka e al.,2021). Howe e , he ole
played by COVID-19- ela ed heal hca e- inancing ulne abili y was no examined.
Va ious ac o s ha e been pu o wa d o explain he downwa d ends in access
o speci ic heal hca e se ices du ing he COVID-19 pandemic ac oss coun ies. The
Pa ne ship o E idence-Based Response o COVID-19 (2020) conduc ed a su ey in
Kenya o assess de e minan s o heal h se ices u iliza ion du ing COVID-19. The au ho s
epo ed ha he main ac o s hinde ing se ice up ake included ea o isk o ca ching
co ona i us a heal hca e acili ies, educed incomes, anspo cos s, heal h- ela ed cos s,
sho age o heal h wo ke s, and di icul ies in accessing heal h acili ies.
Shimeles e al. (2021) epo ed ha low u iliza ion o heal hca e se ices du ing COVID-19
was d i en by una ailabili y and una o dabili y o ca e, inc eased p ices o medica ions,
and in e up ions in ollow-up isi s. Aiello e al. (2008) and Liang e al. (2020) a gued ha
p e-exis ing challenges in access o heal h se ices, such as poo oad ne wo ks, dis up ions in
supplies o heal h acili ies, and limi ed o lack o capaci y o addi ional domes ic heal hca e
inancing. Mo bidi y and mo ali y ou comes o educ ions in a endance we e also s udied
(Apicella e al.,2020). Howe e , none o he s udies conduc ed du ing he COVID-19 pe iod
linked educ ions in clinic a endance o heal hca e inancing ulne abili ies p e ailing a he ime.
3. Da a, Me hodology, and Analy ical F amewo ks
3.1. Da a Sou ces
The pape u ilizes high- equency phone su ey da a collec ed o examine he socio-
economic impac s o COVID-19 in Kenya. These da a we e collec ed h ough a collabo a i e
e o in ol ing he Wo ld Bank, he Kenyan Na ional Bu eau o S a is ics (KNBS), he Uni ed
Na ions High Commissione o Re ugees (UNHCR), and he Uni e si y o Cali o nia, Be keley.
The su ey was conduc ed in i e wa es, namely: (i) Wa e 1: 14 May–7 July 2020; (ii) Wa e 2:
16 July–18 Sep embe 2020; (iii) Wa e 3: 18 Sep embe –28 No embe 2020; (i ) Wa e 4:
15 Janua y–25 Ma ch 2021; and ( ) Wa e 5: 29 Ma ch–13 June 2021. The sample o his s udy
co e s u ban and u al a eas and is gene ally ep esen a i e o he popula ion o Kenya. The
second sample comp ises households selec ed using he Random Digi Dialing me hod. A lis
o andom mobile phone numbe s was c ea ed using a andom numbe gene a o om he
Economies 2025,13, 242 5 o 18
2020 sampling ame p oduced by he Kenya Communica ions Au ho i y. The main ca ego ies
o he ques ionnai e we e designed o collec da a on household backg ound, a el pa e ns
and in e ac ions, employmen , ood secu i y, ans e s, subjec i e wel a e, heal h, COVID-19
knowledge, household s uc u es, and social ela ions.
3.2. Theo e ical Model
Acco ding o Thomas (2021) and ela ed li e a u e, he demand o heal hca e can be
in luenced by heal h needs, household means, and he s anda ds and esou ce equi emen s
o medical p ac ice. Following G ossman’s (1972) heal h p oduc ion model, as adap ed om
Becke (1965), indi iduals alloca e hei esou ces and ime o in es men s ha inc ease
heal h and o he consump ion goods. The bene i s o imp o ed heal h include enhanced
u u e u ili y lows, as well as inc eased ime a ailable o ma ke and non-ma ke p oduc ion.
The o me implies ha heal h is a consume good, while he la e iews heal h as capi al
(a ac o o p oduc ion). Fu he , he model obse es ha heal h is a commodi y ha di e s
om o he goods and se ices in ha indi iduals canno pu chase heal h bu a he , mus
p oduce i hemsel es using pu chased inpu s, complemen ed, as necessa y, by app op ia e
pe sonal beha io s, such as exe cising and abs inence om subs ance abuse. Thus, demand o
heal hca e is de i ed om demand o heal h (H en,2012).
G ossman’s model has ecei ed heo e ical c i icisms, including i s ailu e o add ess
unce ain y and he assump ion ha an indi idual has pe ec in o ma ion conce ning he
decision o maximize u ili y om heal h. The model is also c i icized due o i s asse ion
ha i is p oduced by an indi idual, while in eali y, he majo i y o indi iduals li e
wi hin amilies. Mo eo e , his model does no analyze child en’s demand o heal h and
heal hca e, and u he ails o ake in o conside a ion he ac ha an indi idual’s demand
o heal hca e can be in luenced by he heal h needs o o he amily membe s (H en,2012).
Consequen ly, many models ha ex end G ossman’s o iginal wo k a e conce ned wi h he
abo e issues. In some o he models, pa en s a e assumed o maximize a amily’s u ili y,
a he han an indi idual’s (Rosenzweig & Schul z,1983).
Despi e hese c i icisms, he G ossman model p o ides aluable insigh s in o he
complexi ies o heal h p oduc ion and heal h se ices u iliza ion. The model pa icula ly
illus a es well he in e linkages be ween h ee commonly s udied aspec s in heal hca e
esea ch, namely, he (i) demand o heal h, (ii) heal h se ice u iliza ion, and (iii) heal h
insu ance up ake (H en,2012). The model is applied o he esea ch issue o in e es
in his pape , aking in o conside a ion inno a ions in ela ed heal h se ice u iliza ion
s udies—see, especially (Rosenzweig & Schul z,1983).
3.3. Empi ical Model
We es ima e a heal hca e u iliza ion model in which he main d i e o u iliza ion is
heal hca e inancing ulne abili y a he han he usual use cha ges o an indi idual’s
income (Mu ii hi & Mwabu,2014). This is pe o med by i s cons uc ing a Heal hca e
Financing Vulne abili y Index (HFVI) and hen using his index as he main eg esso in
a s uc u al model o heal h se ice u iliza ion. HFVI is a composi e index o ac o s ha
a e nega i ely co ela ed wi h heal h se ices u iliza ion, such as consul a ion ees, lack
o income, o an ad e se shock. In his s udy, HFVI is ope a ionalized as he inancial
inabili y o pay o heal hca e. Thus, HFVI has elemen s o high use cha ges a heal h
acili ies, household income po e y, ad e se shocks o any kind, plus nega i e e ec s o a
heal h sys em designed wi h insu icien ega d o he economic con ex s o indi iduals
and households. I is also wo h highligh ing ha HFVI is co ela ed wi h unobse able
ac o s o which da a is no a ailable. Howe e , he es ima ion me hod we use— he
Economies 2025,13, 242 6 o 18
con ol unc ion app oach—pa ially accoun s o his p oblem ia he inclusion o he
educed- o m esidual in Equa ion (3) below.
We assume ha an indi idual is heal hca e inancing- ulne able i he pe son is less
likely o a o d he a ailable heal hca e, and consequen ly does no isi a heal h acili y,
o , condi ional on he isi , canno aise he equi ed use cha ge, and hence e u ns home
wi hou ea men . As al eady no ed, HFVI is linked o he heal h sys em. Heal h inancing,
as a unc ion o a na ional heal h sys em, is “conce ned wi h he mobiliza ion, accumula ion,
and alloca ion” o esou ces o co e he cos o people’s heal h main enance—see especially
OECD (2013). The heal h sys em’s heal h inancing unc ion should ensu e ha he cos o
ca e a ailable o people is no beyond hei means.
The HFVI is cons uc ed using he a iables ha inc ease he isk o indi iduals
being unable o use heal hca e se ices p o ided by he heal h sys em. I is wo h no ing
ha a household’s accumula ion and mobiliza ion o unds o pay o heal hca e can be
unde mined by a heal h sys em’s inancing unc ion ha does no ake in o accoun he
economic con ex o households. A hypo he ical case is a heal h sys em ha does no ake
in o accoun he ac ha in some communi ies, he majo i y o households can a o d
nei he use cha ges no insu ance p emiums o con ibu ions.
In he cons uc ion o he HFVI, wo me hods we e used, namely, he Mul iple Co -
espondence Analysis (MCA), as modi ied by Deng and Tian (2015), and he Uncen e ed
P incipal Componen Analysis (UPCA), as a icula ed in Wi enbe g and Leibb and (2017).
Bo h me hods we e used o cons uc a composi e index based on a se o dummy a i-
ables ha p oxy he abili y o pay. Wi enbe g and Leibb and cons uc ed and compa ed
h ee asse indices, namely, he Usual PCA, MCA, and Uncen e ed PCA, whe e he dummy
a iables a e gi en a alue o ze o, no ably o asse possession, and a alue o one, o h-
e wise. The usual PCA and MCA had some nega i e alues o asse indices ha we e
undesi able on he asse scale. Wi enbe g and Leibb and (2017) used Uncen e ed PCA,
which did no ha e nega i e alues, an app oach adop ed in his s udy. Table 1shows he
dummy a iables used o cons uc he HFVI, as well as he codes o he dummies.
The HFVI has been cons uc ed a bo h he na ional and coun y le els, highligh ing
he coun ies ha exhibi ed g ea e suscep ibili y o heal hca e inancing challenges. These
indings a e isually p esen ed on a map o Kenyan coun ies in he esul s sec ion.
The HFVI (H ) is he main d i e o heal hca e u iliza ion since i is cons uc ed using he
a iables ep esen ing a household’s inabili y o pay o ca e (see Equa ion (1)). O he de e -
minan s o se ice u iliza ion include cos o medical se ices, cos o medical equipmen ,
cos o ood i ems, and demog aphics, especially age, gende , ma i al s a us, educa ion,
occupa ion, household size, p e-exis ing heal h condi ions, esidence, and dis ances o
sou ces o ca e.
We use a pooled panel p obi app oach o es ima e he pa ame e s o ou heal hca e
u iliza ion equa ion. The pooled panel model is less es ic i e han he longi udinal p obi
model, bu i wo ks bes when se ial dependence is absen o can be handled by clus e ing
s anda d e o s, al hough i does no explici ly con ol o ime-in a ian unobse ed
he e ogenei y. Assuming he e is no au oco ela ion in ou da ase , using a pooled p obi
model may o e a be e i o he da a han a longi udinal model ha does no accoun o
ime-in a ian unobse able co a ia es—see, Woold idge (2002, pp. 482–485).
Economies 2025,13, 242 7 o 18
Table 1. The Componen s o Heal hca e Financing Vulne abili y Index (HFVI).
Va iable Desc ip ion Reason
Employmen
A dummy a iable aking he alue 1
o no being employed, and a alue
o ze o o he wise.
Pe sons who a e no employed a e mo e
ulne able o he inabili y o a o d heal h
ca e inance han hose who a e employed
(B uce e al.,2022;Ki ole e al.,2023).
Employmen ype
A dummy a iable aking he alue 1
o pa - ime employmen , ze o o
ull employmen .
Those in pa - ime employmen a e mo e
ulne able o lack o unds o pay o
heal h ca e compa ed o hose in ull- ime
employmen (Ki ole e al.,2023)
Heal h insu ance
A dummy a iable aking he alue 1
o no ha ing insu ance,
ze o o he wise;
Pe sons wi hou heal h insu ance a e
mo e ulne able o inabili y o pay o
heal h ca e, a si ua ion ha inc eases HFVI
(Ki ole e al.,2023)
Employe ’s medical bene i s
A dummy a iable aking he alue 1
o no ha ing he employe ’s
medical bene i s, 0 o he wise;
The households wi hou medical bene i s
a e mo e ulne able o inabili y o use ca e
(Ki ole e al.,2023)
Cash paymen s
A dummy a iable aking he alue 1
o no paying o heal h se ices in
cash, and 0 o he wise.
Pe sons paying in cash a e less ulne able
o inabili y o inance heal h ca e (Na ional
Academies o Sciences, Enginee ing, and
Medicine,2018;Houenin o e al.,2023)
Table 1shows ha HFVI is a composi e index o indica o s ha p oxy o a high inabili y o a o d heal hca e. In
he p ocess o agg ega ing da a h ough Uncen e ed PCA, he selec ed a iables we e adjus ed o exhibi posi i e
co ela ions wi h he HFVI concep . This adjus men ensu es ha he a iables a e combined e ec i ely using
Uncen e ed PCA and exhibi he desi ed posi i e co ela ion wi h he inabili y o pay o heal hca e.
We es ima e a pooled panel p obi model o he o m:
Uhci =µ+ηH i +βZi +ui (1)
whe e
Uhci
= U iliza ion o heal hca e se ices p oxied by whe he any membe o he
household isi ed any heal h acili y in he pas 7 days.
H i = Heal h inancing ulne abili y index cons uc ed om Table 1.
ui = Random e o e m.
The coe icien
η
, on
H i
indica es he impac o Heal h Finance Vulne abili y Index
on heal hca e u iliza ion. Since
Uhci
and
H i
a e likely o be join ly de e mined, we
add ess his endogenei y issue by ins umen ing
H i
by he non-sel -mean o
H i
o
e e y coun y (see S auss,1986;Epo e al.,2025). The educed o m equa ion o he Heal h
Financing Vulne abili y Index is:
H V∗
i =µ+βZi +σIVi +εi (2)
whe e
H V∗
i
= Heal h Financing Vulne abili y Index cons uc ed using a composi e index
om he inabili y o pay index.
Zi = ec o o exogenous co a ia es.
IVi
= he non-sel -mean o he Heal h Financing Vulne abili y Index o each o he
47 coun ies, such ha all households in a gi en coun y ha e he same alue o his
ins umen al a iable.
εi = i+ui
= a new composi e e o , whe e is ixed, and u is an idiosync a ic e m.
To add ess he e ogenei y emana ing om he non-linea in e ac ion o HFVI wi h he
unobse able a iables in he e o e m, we cons uc an in e ac ion a iable be ween
Economies 2025,13, 242 8 o 18
HFVI wi h he p edic ed esidual o he HFVI as an addi ional eg esso o ob ain he
ollowing exp ession:
Uhc∗
i =α+λH ii +βZi +γH i esidi +π(H i esid ∗H i)i +εi (3)
The esidual (
H i esid
) se es as a con ol unc ion a iable ha ende s HFVI exogenous
(Woold idge,2015;Mwabu,2009). As no ed, he in e ac ion e m
(H i esid ∗H i)
add esses
he unobse ed he e ogenei y o he coe icien on HFVI, keeping i cons an ac oss uni s o
analysis,
εi
is a composi e e o e m comp ising he andom and he non andom, ixed
pa o he e o e m, and α,λ,β,γ, and πa e ec o s o pa ame e s o be es ima ed.
Table 2p o ides he de ini ion and measu emen o he a iables used in ou model es ima ion.
Table 2. De ini ion o Va iables.
Va iables Measu emen
Dependen Va iable
U iliza ion o heal h ca e se ices A dummy a iable aking he alue 1 i any membe o he household
isi ed any heal h acili y in he pas 7 days, 0 o he wise
Explana o y Va iables
Heal h Financing Vulne abili y Index (HF )This is a con inuous a iable cons uc ed om dummy a iables in Table 1
using Uncen e ed PCA
The Z ec o in Equa ion (3) con ains:
The na u al loga i hm o he cos o medical se ices,
including medical and non-medical cos s
A con inuous a iable indica ing he na u al loga i hm o he o al amoun
in Kshs paid o he i em(s)/se ice(s) used in se ice deli e y
The na u al loga i hm o he cos o o he ela ed commodi ies,
such as ood
A con inuous a iable indica ing he na u al loga i hm o he o al amoun
in Kshs paid o ood i ems
Ma i al S a us o an indi idual A dummy a iable ha akes he alue 1 i one is ma ied, 0 o he wise
Residence A dummy a iable aking he alue 1 i an indi idual esides in an u ban
a ea, 0 o he wise
Gende A dummy a iable aking he alue 1 i an indi idual is male, 0 o he wise
The na u al loga i hm o he age The na u al loga i hm o he age o an indi idual in yea s
P ima y Educa ion Le el A dummy a iable aking he alue 1 i an indi idual has p ima y
educa ion, 0 o he wise
Seconda y Educa ion Le el A dummy a iable aking he alue 1 i an indi idual has seconda y
educa ion, 0 o he wise
Uni e si y Educa ion Le el A dummy a iable aking he alue 1 i an indi idual has a uni e si y
educa ion, 0 o he wise
The na u al loga i hm o he household size A con inuous a iable indica ing he na u al loga i hm o he o al numbe
o household membe s
P e-exis ing heal h condi ions A dummy a iable aking he alue 1 i he e is a p e-exis ing heal h
condi ion, such as diabe es, e c., 0 o he wise
Ins umen al Va iable (IV)
This is a non-sel -coun y mean o HFVI cons uc ed by ge ing he coun y
mean o all HFVIs, excep o he index o indi idual i, so ha he mean is
exogenous o indi idual i.
P edic ed esidual o HFVI, i.e.,
HFVI esidi
This is a con inuous a iable gene a ed om a educed- o m eg ession o
he po en ially endogenous HFVI on all exogenous a iables and he
ins umen al a iable
In e ac ion o he p edic ed esidual wi h HFVI, i.e.,
(HFVI esid ∗HFVI)i
This is a con inuous a iable gene a ed by in e ac ing he p edic ed esidual
o HFVI wi h he po en ially
endogenous HFVI
3.4. S udy Limi a ions
In in e p e ing he e idence p esen ed in Sec ion 4o in using i o in o m policy,
he ollowing conside a ions should be bo ne in mind. The dependen a iable in he
empi ical model, i.e., heal h se ice u iliza ion in he pas 7 days, migh be inco ec ly
measu ed because some cu en heal h condi ions can necessi a e heal h se ice u iliza ion
Economies 2025,13, 242 15 o 18
Table 6. Con .
Va iables P obi Ma ginal E ec s
Uni e si y le el (=1) 0.1716 ***
(0.0329)
P e-exis ing condi ions (=1) 0.6006 ***
(8.46)
Log Household size −0.1365 ***
(0.0173)
HFVI_p edic ed esidual 0.3113 ***
(0.0182)
In e ac ion o HFVI wi h p edic ed esidual −0.0001
(0.0001)
No es: *** p
≤
0.01; s anda d e o s a e in pa en hesis. Sou ce. Au ho s’ Own Compu a ions Using he
Wo ld Bank (2020) COVID-19 Da a.
5. Conclusions and Policy Implica ions
The s udy has measu ed he impac o HFVI on he u iliza ion o heal hca e acili ies
in Kenya du ing he COVID-19 pandemic. The econome ic e idence shows a consis en
and s a is ically signi ican nega i e associa ion be ween heal hca e inancing ulne abili y
wi h heal h se ice u iliza ion. The measu es aken by he go e nmen o con ain he
pandemic seem o ha e wo sened households’ inabili y o a o d heal hca e. Lockdown
measu es plus COVID-19- ela ed sicknesses, oge he o sepa a ely, led o job losses and
likely inc eased people’s inabili y o a o d medical insu ance o a el cos s o sou ces o
ca e. App op ia e iscal measu es and social ans e s in imes o disease pandemics can
subs an ially educe heal hca e inancing ulne abili ies in he popula ion and p o ec bo h
heal h and li elihoods. Mo eo e , since heal h is in insically connec ed o schooling and
lea ning, such policies can u he p o ec he o ma ion o educa ion capi al in pe iods
o disease pandemics. We ha e shown ha heal h inancing ulne abili y index a ies
subs an ially by egion, wi h coun ies in he no h-eas e n pa o Kenya ha ing he highes
ulne abili y indices, which sugges s ha geog aphic a ge ing o bo h iscal bene i s
(e.g., exemp ions om some ax ca ego ies), and social ans e s o he needies social
g oups, can p o ec human capi al o ma ion in all communi ies in pe iods o pandemics.
Ou s udy sugges s ha speci ic in e en ions o educe heal hca e inancing ulne a-
bili y (HFV) in he gene al popula ion migh no wo k. We ha e shown ha HFVI is d i en
by i e key ac o s:
(i) no ha ing heal h insu ance; (ii) lack o o mal employmen ; (iii) lack o cash o
liquidi y; (i ) no ha ing medical bene i s a place o wo k; and ( ) high ca as ophic
heal h expendi u es, i espec i e o abili y o pay because hese heal hca e ou lays can
d i e pe sons abo e he po e y line o ex eme po e y (Ogwang & Mwabu,2025), o
push hose below he po e y o des i u ion. Looking a (i) o ( ) abo e, i is clea ha
HFV in a pandemic con ex is no jus a lack o money, employmen , o insu ance. The
gene al pe o mance o he economy also ma e s, as he s a e o he economy de e mines
whe he o no he ype o heal hca e people wan is a ailable. Mo eo e , he needed
heal hca e migh be a ailable, bu he na ional heal h sys em migh no deli e i e icien ly
o equi ably. Thus, in addi ion o speci ic in e en ions implied by he componen s o
HFVI, policies o imp o e he pe o mance o he whole economy a e needed in c isis imes.
Equally impo an a e go e nance ins i u ions ha can be elied upon o make he bes
possible social decisions in a pandemic con ex . Fu he mo e, c i ical in such a con ex is a
mass communica ion echnology o acili a e popula ion-wide sha ing o i al in o ma ion
abou pandemics in eal ime.
Economies 2025,13, 242 16 o 18
Au ho Con ibu ions: Concep ualiza ion, M.M. and M.O.; li e a u e e iew, M.M. and M.O.; me hod-
ology, M.M.; w i ing o iginal d a , M.M.; supe ision o he pape as well as being he co esponden ,
M.M.; da a analysis, M.O. and F.K.; e iewing and edi ing o he pape , M.O. and T.M.; da a cu a ion,
F.K.; p oo eading and alida ion o he pape , F.K.; da a sou cing, T.M. All au ho s ha e ead and
ag eed o he published e sion o he manusc ip .
Funding: The unding o his esea ch p ojec was done by he A ica Economic Resea ch Conso -
ium (AERC) based in Nai obi, g an numbe RC 22520 da ed 27 July 2022, unde he con ex o a
collabo a i e p ojec on “add essing heal h inancing gaps and ulne abili ies in A ica due o he
COVID-19 Pandemic”.
Da a A ailabili y S a emen : The pape u ilizes high- equency phone su ey da a ha examines he
socio-economic impac s o COVID-19 in Kenya. These da a we e collec ed h ough a collabo a i e
e o in ol ing he Wo ld Bank, he Kenyan Na ional Bu eau o S a is ics (KNBS), he Uni ed Na ions
High Commissione o Re ugees (UNHCR), and he Uni e si y o Cali o nia, Be keley. The su ey
was conduc ed in i e wa es, wi h he ollowing da a collec ion pe iods: (i) Wa e 1: 14 May o
7 July 2020; (ii) Wa e 2: 16 July o 18 Sep embe 2020; (iii) Wa e 3: 18 Sep embe o 28 No embe 2020;
(i ) Wa e 4: 15 Janua y o 25 Ma ch 2021; and ( ) Wa e 5: 29 Ma ch o 13 June 2021. This da a was
accessed h ough h ps://mic oda a.wo ldbank.o g/index.php/ca alog/6069, accessed on 10 May 2023.
Con lic s o In e es : The au ho s decla e no con lic o in e es .
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