# The hidden costs of ‘free’ treatment: A cross-sectional study of patient-incurred costs for daily methadone maintenance treatment in Nairobi, Kenya

## TL;DR

This study explores the hidden costs patients face when accessing free methadone treatment in Nairobi, Kenya, revealing significant time and financial burdens that may hinder treatment adherence.

## Contribution

The study quantifies patient-incurred costs of daily methadone maintenance treatment in a low-resource setting, highlighting barriers to treatment continuity.

## Key findings

- Patients spent a median of $22.6 per month on direct costs and $26.9 on income loss.
- Higher education, income, and employment were linked to greater costs and income loss.
- Decentralized services and take-home dosing are recommended to improve treatment accessibility.

## Abstract

Methadone Maintenance Treatment is one of Kenya’s evidence-based interventions and is stipulated in national policies and guidelines as both a harm reduction and addiction management intervention for opioid use disorder. It is provided free of charge at public health facilities where patients are required to come daily for treatment. Despite being free, patient-incurred costs such as transport, lost income and other daily expenses may pose barriers for treatment continuity, particularly in low resource settings such as Kenya. This cross-sectional study examined patient-incurred costs of daily methadone maintenance treatment (MMT) at a national teaching and referral hospital in Nairobi, Kenya. A total of 249 patients (80.32% male, 19.68% female) were surveyed using a socio-demographic questionnaire and a modified Drug Abuse Treatment Cost Analysis Program: Client (Outpatient) Version. Descriptive statistics and non-parametric tests were used to explore the association between patient demographic characteristics and treatment costs. Key findings showed a median age 40 years (IQR: 33–45), with 83.53% having a monthly household income $134.42. Patients travelled an average distance of 10 km daily and spent approximately 24 hours weekly seeking treatment. The median total direct cost was $ 22.6 per month (IQR: $13.2 – 37.6), while the median monthly income loss was $26.9 (IQR: $13.4 - $43.7). Female gender, higher education levels, household incomes, and current employment were significantly associated with greater costs and income losses (p < 0.05). Although MMT is free in Kenya, patients spent considerable time and opportunity costs in seeking treatment potentially compromising treatment adherence and long-term treatment outcomes. These findings suggest a need for decentralized services, take home dosing, and integrated livelihood programs to enhance MMT accessibility and effectiveness in resource-limited settings.