Informal payments for family planning: prevalence and perspectives of women, providers, and health sector key informants in western Kenya

Figures & data

Table 1. Methodologies employed to assess the prevalence and impact of informal payment solicitation among 56 public sector healthcare facilities in western Kenya, 2018–2019

	Family planning mystery client observations	Observations of client provider interactions during family planning provision	Focus group discussions with current and former family planning clients	Key informant interviews with health sector stakeholders	Family planning patient and provider journey mapping workshops
Brief Description of Procedure	Data collectors pretended to be real family planning clients seeking services from public sector providers; providers were unaware that the mystery client was collecting data for research purposes.	Third party data collectors were present in the consultation and/or exam room during family planning provision and observed the interaction between real patients and their providers.	A facilitator-led discussions among groups of six to eight women of reproductive age to identify group norms and common and diverse experiences around seeking family planning services from public sector facilities.	An interviewer held in-depth one-on-one interviews with knowledgeable individuals who can provide first-hand perspectives on family planning provider behaviours and feasible, practical, and acceptable solutions to informal payments.	We created patient and provider journey maps to visually represent a sequence of touchpoints where the family planning clients interact with the public sector health system. In the commercial sector, journey maps are used to identify every consumer interaction with the company and then to identify ways to optimise customer retention.
Advantages	Enables researchers to observe how providers behave when they are unaware they are being watched and produces valid estimate of the prevalence of informal fees; well-suited for measuring hidden behaviours such as informal fees. Not subject to long recall periods or participant confusion over legitimate versus illegitimate fees.	Enables researchers to observe real family planning clients. Not subject to recall bias or participant confusion over legitimate versus illegitimate fees.	Enables researchers to capture the larger and nuanced impacts of informal payments on women seeking family planning.	Enables researchers to capture the larger and nuanced impacts of informal payments on women seeking family planning. Solicits feasible, practical, and culturally appropriate solutions to informal payments.	Enables researches to assess whether they have captured a complete picture of facility-level barriers to family planning use such as informal payments.
Limitations	Mystery clients cannot mimic all aspects of a real family planning client and may not represent the diversity of women seeking family planning. Mystery clients, as data collectors, cannot comment on the larger and nuanced impacts of informal payments on women seeking family planning. Mystery clients are not well placed to provide in-depth descriptions of solutions to informal payments.	Providers may alter their behaviour when they are aware they are being watched; this is especially true when measuring hidden or illicit behaviours such as informal payments. Client-provider observations do not capture the larger and nuanced impacts of informal payments on women seeking family planning nor do they provide data on feasible solutions.	Cannot provide an estimate of the prevalence of informal payments for family planning provision.	Cannot provide an estimate of the prevalence of informal payments for family planning provision.	Cannot provide an estimate of the prevalence of informal payments for family planning provision.