Can a private sector engagement intervention that prioritizes pro-poor strategies improve health care access and quality? A randomized field experiment in Kenya.

Private sector engagement in health reform has been suggested to help reduce healthcare inequities in sub-Saharan Africa, where populations with the most need seek the least care. We study the effects of African Health Markets for Equity (AHME), a cluster randomized controlled trial carried out in Kenya from 2012-2020 at 199 private health clinics. AHME included four clinic-level interventions: social health insurance, social franchising, SafeCare quality-of-care certification program, and business support. This paper evaluates whether AHME increased the capacity of private health clinics to serve poor clients while maintaining or enhancing the quality of care provided. At endline, clinics that received AHME were 14.5 percentage points (pp) more likely to be empaneled with the National Health Insurance Fund (NHIF), served 51% more NHIF clients, and served more clients from the middle 3 quintiles of the wealth distribution compared to control clinics. Comparing individuals living in households near AHME treatment and control clinics (N=8241), AHME led to a 6.7pp increase in the probability of holding any health insurance on average. We did not find any additional effect of AHME on insurance holding among poor households. We measured quality of care using a standardized patient (SP) experiment (N=596 SP-provider interactions) where recruited and trained SPs were randomized to present as either "not poor", and able to afford all services provided, or "poor" by telling the provider they could only afford approximately 300 Kenyan Shillings (US$3) in fees. We found that poor SPs received lower levels of both correct and unnecessary services, and AHME did not affect this. More work must be done to ensure clients of all wealth levels receive high quality care.