Insurance coverage, healthcare use, and outpatient payment among adults with disability in Kenya before the SHA transition: a secondary analysis of KDHS 2022

Background: Adults with disability tend to need more healthcare and to have less capacity to pay for it. Kenya replaced the National Hospital Insurance Fund (NHIF) with the Social Health Authority (SHA) in October 2024, so KDHS 2022 is the last pre-transition national survey containing these measures. We examined differences by disability status in health insurance coverage, healthcare use, and outpatient payment before the transition, including how insurance coverage varied across disability severity and what could be observed about insurer contributions at the point of care. Methods: Cross-sectional analysis of the KDHS 2022 person recode, covering adults aged 18 and above in the long-questionnaire subsample that carried the disability, insurance and service-use modules. Disability used the Washington Group Short Set (WG-SS). Survey-weighted quasi-Poisson models gave prevalence ratios under three adjustment sets with marginal standardised differences; severity categories were contrasted directly; amounts and payer sources were analysed among those who reported paying, with bounds where payer source is unrecorded. Results: Of 40,197 adults, 6.7% met the WG threshold. Uninsurance was higher among them unadjusted (PR 1.10) and after adjustment for sex, age group and residence (PR 1.10, 95% CI 1.06 to 1.13; +6.7 percentage points), and was attenuated after adding wealth and education (PR 1.01, 95% CI 0.98 to 1.04; 0.6 percentage points, 95% CI -1.3 to 2.5). Outpatient use and hospitalisation were higher in every specification (fully adjusted PR 1.63, 14.0 percentage points, 95% CI 11.7 to 16.3; and PR 2.15, 7.7 percentage points, 95% CI 5.9 to 9.6; both p < 0.001). Among outpatient users with disability, 90.5% reported paying, insured or not. Among respondents who reported paying, insurance was associated with a lower probability that any part of the payment was made in cash (PR 0.89, p < 0.001), while among those who did pay cash the conditional cash amount was higher. Among insured outpatient users with disability who reported paying and had a recorded payer split, 15.1% had a recorded insurer contribution. Because payer information was not collected when no payment was reported, the corresponding proportion among all insured outpatient contacts was bounded between 11.9% and 32.9%. Conclusions: Adults with disability had higher crude uninsurance, but this difference was attenuated to the null after adjustment for wealth and education. They also had substantially higher outpatient use and hospitalisation, which persisted under every adjustment set. Most outpatient users reported making a payment at their last visit regardless of insurance status, while the insurer contribution could only be partially observed because payer information was not collected when no payment was reported. These estimates provide a pre-transition benchmark, against which SHA-era measurement should assess payment at the point of care alongside insurance coverage.