NHIF’s attempt to limit hospital visits ill-advised

Swedish statistician Hans Rosling became famous for lectures combining enormous quantities of public data on global health with a sport’s commentator style to explore development issues.

But insofar as evidence-based policy management is concerned, the bigger challenge always lies in the fact that decision-makers mostly want politically convenient sound-bite advice and not substantive advice.

So when the National Hospital Insurance Fund (NHIF) issued a directive limiting outpatient visits to only four per year, the directive even though later reversed, surprisingly inverted both the pros and cons of evidence-based policy management at the same time.

The ill-advised directive was not only politically inconvenient looking at the heated response it attracted and its ultimate reversal but it also attempted to repeal a standard economic theory well evidenced in the developed world about health insurance coverage: That the value of insurance for coverage of unaffordable care is derived from the value of the medical care that insurance makes accessible.

In short, the positive effect of health insurance is to open access to better health services. Therefore to limit access to only four visits per family for the whole year is as good as not taking the health cover.

This raises serious concerns about how our institutions in the health sector arrive at policy-decisions.

But the NHIF is just a smoking gun to the monumental problem facing the financing of our health system.

Kenya just like many African countries is still stuck with the colonial history of healthcare being a government issue through supply-side funding of free public services when the inherent affliction of this policy is well chronicled from Eastern Europe countries to the Latin and many African countries.

Inefficiency, being less responsive to individual preference, inadequate funding due to overwhelming budgets as well as poor quality services are always the footprints it leaves behind and Kenya already has its own fair share.

First, the government has implemented free maternal care in public facilities launched in 2013 but the country is moving up the ranks of top countries with high maternal mortality rates, from 488 in 2013 to 510 deaths per 100,000 live births according to the latest data from the United Nations Children Fund.

Second, the government also implemented free primary care in lower-level public facilities but malaria persistently remains a serious health problem with a prevalence rate of eight per cent, as HIV/Aids, perinatal conditions and malaria account for 24.2 per cent, 10.7 per cent and 7.2 per cent causes of disabilities respectively.

Despite great strides in tuberculosis control, it is estimated that 19 per cent still remain undetected, which is attributed to barriers to healthcare access.

To show how dysfunctional the financing of our health system is, total government health expenditure as a proportion of the total budget (both national and county budget) is among the lowest in the region at about 6.8 per cent, falling much below the 15 per cent agreed by African governments in Abuja in 2003.

Of that amount, personnel costs shockingly account for 70-80 per cent of total recurrent budget for health at both national and county levels. And 20 per cent of the personnel costs go to paying people at the Ministry of Health who do not see any patient.

Due to the government’s low health expenditure and health insurance both public and private that’s meant to provide financial protection contributing a paltry 18 per cent in the healthcare financing system.

Kenyans are therefore forced to contribute more in finance their healthcare through out-of-pocket spending which stands at 32 per cent leading to an estimated 6.8 per cent (2.6 million) of Kenyans being pushed below the poverty line every year since they spend over 40 per cent of their non-food expenditure on health.

Looking into the future, the greater danger that looms in our health system is the collapse of primary care due to our present design of the NHIF, which currently covers only 6.6 million (15 per cent of Kenyans) and seeks to expand coverage to the greater number of people who are uninsured.

READ: NHIF pays Sh5.9bn medical bills in four months

Data from the Ministry of Health suggest that there is increased utilisation of primary health facilities that serve close to 27-30 million people. So one would expect that more public funding will be channelled towards strengthening primary care.

But as currently designed the NHIF incentivises the use of hospital care, brushing aside the financing of primary care and as evidenced in India the referral system breaks because patients just turn up straight in the hospital and get admitted, leaving primary care poorly funded and organised.

In conclusion, with limited resources to finance provision of healthcare services with a greater population floating around and below the poverty line.

Health policy makers need to consider restructuring the financing of our healthcare system away from supply-side funding of free public services towards a demand-side funding through a comprehensively integrated national health insurance (contributory and subsidised regimes of even those below poverty line).

This is the best financing option with greater development impact as evidenced in successful countries like Namibia, Ghana, Costa, Rica, Peru, and Colombia.

The success of a health insurance being pro-poor has more to do with a purposive effort to design health insurance in a way that benefits the poor.

Tony Watima is an independent economist.