Under-cover in Kenya: the contribution of non-state actors to mental health coverage

Half of health care in sub-Saharan Africa is privately provided, however, for mental health, the literature is all but absent on these services. Kenya provides a useful case-study, as it has a wellorganized non-state sector and data are readily available. My thesis asks what contribution do non-state actors make to coverage for mental disorders in Kenya? Non-state mental health care is conceived along two axes: for-profit vs. not-for-profit and formal vs. informal. Four empirical chapters use mixed-methods to examine: 1) not-forprofit NGO care; 2) for-profit inpatient care; 3) for-profit outpatient care; and 4) traditional and faith healing. Data were collected on 774 service users and 120 service providers from four primary sources, and two secondary sources, as well as from a wide range of key-informant interviews. The first two chapters set the research question within the context of existing knowledge in the fields of health economics and health services research. The third chapter provides an overview of methods, focusing on cost-effectiveness analysis, case study method, and crosscultural psychiatric epidemiology. The first empirical chapter presents an NGO intervention called the model for Mental Health and Development, evaluated qualitatively and quantitatively, using cost-effectiveness analysis. The second empirical chapter offers a case study of a growing private psychiatric hospital, using regression analysis on the effects of insurance on charge and service use. The third chapter is a short descriptive analysis of a questionnaire completed by psychiatric nurses about their participation in mental health care, and structured interviews with specialist outpatient providers. The final empirical chapter contains qualitative and quantitative data on traditional and faith healing, analysed for similarities and differences. The conclusion ties together findings thematically according to capacity, access and cost, estimating the degree of mental health care coverage offered by non-state actors in Kenya, and offering lessons for policy and research