Private sector workers seeking outpatient medical treatment from leading public and private hospitals are being turned away even as the National Hospital Insurance Fund (NHIF) continues to collect higher monthly fees with the promise of expanding the range of benefits available to the contributors.
The Business Daily can report that the majority of hospitals are rejecting NHIF cards for outpatient treatment because they are yet to agree with the insurer on the controversial capitation levels necessary for each family.
This has left NHIF’s private sector members with a small number of bottom and middle-level hospitals most of which offer low quality services.
Major private hospitals such as Nairobi, Aga Khan and Mater have rejected the NHIF medical scheme, insisting that the capitation levels are too low.
Besides the top non-government hospitals, private sector workers cannot access outpatient healthcare at key public facilities such as Moi Teaching and Referral Hospital in Eldoret, Coast Provincial General Hospital (Mombasa) and Nairobi-based Kenyatta National Hospital (KNH).
This is despite the fact that NHIF more than quadrupled monthly deductions beginning April last year promising more benefits, including outpatient treatment in all facilities.
Senior hospital managers yesterday said talks were ongoing to grant private sector workers access to outpatient hospitals using NHIF cover, but did not offer any timelines.
“We are at advanced stages of discussion with NHIF before we sign the contract and roll it out,” said KNH chief executive Lily Koros.
NHIF had promised members access to medical care in private, public and faith-based hospitals such as Kiambu-based PCEA Kikuyu Hospital, which is also yet to open its doors to private sector workers for outpatient treatment.
Enquiries at the major public hospitals established that private sector workers are only eligible for the long-running inpatient care for which they can use the NHIF cover to offset part of the bed charges.
Civil servants are, however, enjoying both inpatient and outpatient services at selected public and private hospitals they have selected under the scheme, a situation that is brewing discontent among private sector workers.
Unlike government workers, private sector employees are also being denied access to advanced medical examination procedures like endoscopy, CT and MRI scans in public and faith-backed facilities.
Machakos Level Five Hospital, for instance, allows both public and private sector workers to access outpatient care. but private sector employees are restricted to kidney dialysis, diabetes, basic X-rays, minor surgeries and basic care for ailments like malaria and typhoid.
Officials at mission facilities like Tenwek Hospital in Bomet, gave a similar position. Jaramogi Oginga Odinga Teaching and Referral Hospital in Kisumu is the only referral facility that is accepting both public and private sector workers.
The NHIF pays Sh2,850 to hospitals per year towards outpatient care for each public servant, which is Sh1,650 more than the capitation of Sh1,200 for non-government workers.
The agency last April increased monthly contributions from Sh320 to Sh1,700 for top earners with the promise of enhanced benefits that have yet to be delivered.
The public health insurer had, for instance, assured contributors access to the better equipped private hospitals from July last year, three months after the April increase in monthly contributions.
Implementation of the scheme, which is part of the government’s strategy to achieve universal healthcare, has however run into serious headwinds after the fund failed to reach a capitation deal with private hospitals.
Private health service providers like Nairobi Hospital, Aga Khan, Mater, MP Shah, which are better staffed and equipped, have shunned the medical scheme, saying it is unsustainable.
They have rejected the Sh1,200 cash allocation that the NHIF has offered to pay them annually (capitation) for every beneficiary, saying it is too little.
Under the scheme, the national health insurer pays Sh1,200 annually to a facility that the contributor and his family have chosen and where they are given access to services without cost limits.
Removal of cost limits favours low-income households who are often hard-pressed to raise cash for emergency treatment but has not worked for private sector workers, most of who depend on private insurance plans.
Efforts to reach NHIF chief executive Simeon ole Kirgotty were unsuccessful as our phone calls went unanswered.
The outpatient cover was expected to offer treatment for sexually transmitted diseases, renal dialysis, X-rays and minor surgical operations.
Before last year’s revision of the monthly fees, formal sector workers paid a uniform Sh320 to the fund for inpatient care. That entitled contributors to a daily Sh2,400 rebate, mainly to settle the cost of a patient’s hospital bed.
NHIF contributors are also entitled to a maternity cover of Sh6,000 for normal delivery while Caesarean section is covered up to Sh18,000 for a four-day stay.
NHIF last week said it plans to increase maternity cover to Sh10,000 for normal delivery and Sh30,000 for C-section. Kidney dialysis is now covered up to Sh10,000 per session from the previous Sh2,000.
The agency also plans to establish a fund to finance outpatient treatment for chronic diseases like cancer, diabetes, kidney failure and hypertension in public and private hospitals.
Last year, it announced plans to start paying up to Sh5 million in hospital bills for members with chronic illnesses seeking treatment abroad.