Kenya & Nepal: Primary Care Functions

Citizen charters are a facility-level intervention that can increase accountability and empower patients to advocate for their rights. In Kenya, service charters are expected to be displayed in all health facilities. In addition to patient rights, they are also expected to include information on available services, corresponding costs, facility hours, and names and contact information of health facility committee members. Additionally, all information should include local language translations.1 An evaluation of health facility charters in the Kericho District found that implementation of these charters differed substantially; none of the facilities met all of the requirements. In this district, the majority (66%) of patients surveyed were aware of the charters, 84% of these had read the information, and 83% of those who read them found it useful. The financial information was most useful to patients; the listed costs of services made patients feel that the facility was more transparent, helped them plan their finances, and gave them an opportunity to dispute charges that they thought were unfair. However, they did not feel that the charters made providers more responsive to their concerns. Some attributed this challenge to social expectations and norms that prevented them from openly discussing issues they encountered at the health facility. While this case highlights the financial utility of charters, it did not fulfil all of its expected purposes related to respectful care, and implementation was a challenge.

In Nepal, PHC facilities adopted facility charters in the early 2000s. Compared to Kenya, an evaluation of the implementation of charters in the Dang district in Nepal found far less awareness of charters. Only 15% of patients were aware of charters and two-thirds of these had read them.2 Some participants noted that the charter made them aware of the services that were provided, but like Kenya few felt that it enabled them to dispute care that did not align with the charter. Some implementation challenges that were identified through the evaluation of these charters included lack of consultation with the community on the purpose and content of the charter, inadequate training on the charters within facilities, lack of punitive or corrective action when the charter is not followed, and an absence of ownership of the charter and its principles from providers at the facility. Additionally, many patients in this region are illiterate, and no efforts were made to convey this information to them. Although service charters were more successful in Kenya, both cases demonstrate limited use in enabling social accountability. However, charters may be a useful starting point for identifying facility values and services, but they must be paired with community engagement during development and implementation, provider ownership, and monitoring and sanctions for non-adherence.


  1. Atela M, Bakibinga P, Ettarh R, Kyobutungi C, Cohn S. Strengthening health system governance using health facility service charters : a mixed methods assessment of community experiences and perceptions in a district in Kenya. BMC Health Serv Res [Internet]. 2015;1–12. Available from:
  2. Gurung G, Fellow P, Ma RG, Philip D, Bhb CH, Chb MB, et al. Citizen’s Charter in a primary health- ­ care setting of Nepal : An accountability tool or a “ mere wall poster ”? 2018;(June 2017):149–58.