Millions of private sector workers cannot access outpatient medical services at private hospitals using the State health insurer’s cover, even as the agency continues to deduct higher monthly contributions pegged on an increase in the range of services offered.
Thousands of contributors who tried to use the National Hospital Insurance Fund (NHIF) cover for treatment at private hospitals were last week turned away, nearly four months since the agency more than quadrupled monthly contributions on the promise of more benefits, including outpatient treatment.
The NHIF had assured contributors access to the better equipped private hospitals from July 1, three months after the April increase of monthly deductions.
Private hospitals have, however, continued to reject the Sh1,200 cash allocation that the NHIF has offered to pay as annual fee (capitation) for every beneficiary, describing it is too little.
Civil servants and members of the disciplined forces, however, continue to enjoy inpatient and outpatient services at both public and top private facilities, a development that has sparked an outcry from workers in private firms.
NHIF chief executive Simeon ole Kirgotty on Friday admitted that private sector workers under the NHIF outpatient scheme could not register for care at private facilities because they were yet to sign a service agreement.
“We are yet to reach a deal with them (private hospitals) but are negotiating,” Mr Kirgotty said on phone.
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.
This removal of cost limits favours low-income households who are often hard-pressed to raise cash for emergency treatment, causing persistent crowding in public facilities.
The NHIF pays Sh2,850 to hospitals per year towards outpatient care for each public servant, which is Sh1,650 more than the capitation for non-government workers.
The failure to strike a deal with private hospitals has now restricted contributors to seek medical care in public facilities.
The NHIF in April increased monthly contributions from Sh320 to Sh1,700 for top earners with the promise of enhanced benefits, including the introduction of outpatient services.
But implementation of the scheme, which is part of the government’s strategy to achieving universal healthcare, has not been smooth.
A public servant, Sam Okumu, said that on top of paying the monthly maximum premium (Sh1,700) to the NHIF, he is entitled to a medical allowance of Sh4,000 per month which is also channeled to the fund, an arrangement that allows his children to access healthcare at Gertrude’s – a top private hospital for minors.
Before April, all formal sector workers paid Sh320 to the fund for inpatient care where the NHIF pays 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 C-section is covered up to Sh18,000 for a four-day stay.
Mr Kirgotty said 906 hospitals, mostly public and faith-based facilities, had signed up to serve NHIF contributors down from the list of 1,128 that the public health insurer published in June and 1,500 a month earlier.
He, however, did not indicate how much the NHIF had collected since April. In July, the fund said it had collected Sh3.2 billion to be paid to hospitals as capitation.
Small and mid-sized private hospitals, through their lobby, had in principle accepted the Sh1,200 in August following negotiations but made a U-turn after the NHIF refused to agree to their demands.
“We have not yet opened doors to beneficiaries of the NHIF scheme,” said Kenya Association of Private Hospitals (Kaph) chairman John Nyaumah.
“They (NHIF) have refused to allow us to sign up beneficiaries according to the capacity of facilities.”
Dr Nyaumah had proposed that large hospitals be allowed to sign up to 35,000 people – which translates to an annual capitation of Sh42 million based on the Sh1,200 per beneficiary.
Small facilities were to handle 5,000 people, translating to Sh6 million per year. The alternative was for NHIF to increase the annual capitation to Sh6,000 per beneficiary.
Top tier hospitals including Nairobi Hospital, Aga Khan, Mater, MP Shah and Gertrude’s – which are separately represented by the Kenya Associations of Hospitals – have rejected the scheme.
Kaph – which represents over 400 small and mid-sized private hospitals, including Nairobi Women’s, Lang’ata and Karen – had agreed to provide basic care for ailments like malaria and typhoid for the Sh1,200, excluding treatment for cancer, diabetes and blood pressure.
But the NHIF argues that exclusion of chronic diseases would be against the government’s promise to cover every ailment at both public and private facilities, which was part of the reason for the steep increase in monthly contributions.
In addition to chronic diseases, the new outpatient cover was expected to offer treatment for sexually transmitted diseases, renal dialysis, X-rays and minor surgical procedures.