NHIF contributors lose out on cover for top chronic diseases

Contributors to the National Hospital Insurance Fund (NHIF) will not get outpatient treatment for chronic diseases like cancer, diabetes and hypertension at private hospitals in the enhanced medical scheme, calling into question the promises the public health insurer made as it promoted the programme.

Instead, the contributors will only receive basic care for ailments like malaria, pneumonia and typhoid.

The second-tier private hospitals, which had yet to sign up for the State-backed scheme that came into force on July 1, said they had agreed to provide minor care after accepting the NHIF’s Sh1,200 offer as annual capitation per beneficiary.

The Sh1,200 is the set amount paid for every patient under the scheme enrolled at a particular facility, whether or not one seeks care during that period.

The decision came after the NHIF and Ministry of Health mandarins on August 18 held a meeting with the Kenya Association of Private Hospitals (Kaph) to hammer out a deal that would grant beneficiaries access to the top health facilities.

“We had a meeting with our members and they agreed,” Kaph chairman John Nyaumah told the Business Daily, saying that each facility would be assigned a certain number of people based on their capacity.

Kaph — which represents over 400 small and medium-sized private hospitals across the country, including Nairobi Women’s, Lang’ata and Karen — had initially rejected the Sh1,200 capitation amount, saying it was little.

The association, however, said the hospitals will not provide treatment for cancer, diabetes, high blood pressure or offer dental care and diagnostic services such as CT scans because the “capitation cash cannot allow”.

“Members have agreed to offer only treatment for malaria, typhoid, pneumonia, wounds and burns, alongside ear, nose and throat diseases and other minor services,” said Dr Nyaumah.

Top tier hospitals are not taking part in the scheme at all.

READ: NHIF to shut out high cost private hospitals

NHIF chief executive Samuel ole Kirgotty could not be reached on the phone for comment.

The exclusion of chronic diseases goes against the government’s promise to include them in the cover at both public and private facilities to justify increasing monthly contributions to the NHIF in April.

In addition to chronic diseases, the new outpatient cover was expected to offer treatment for sexually transmitted diseases, renal dialysis and X-rays and pay for minor surgical procedures.

Kenyan low-income households are often hard-pressed to raise cash for treatment of chronic diseases at private hospitals, with many crowding the few cheaper public facilities.

In March, for instance, more than 1,000 cancer patients were on the waiting list at Kenyatta National Hospital (KNH) in Nairobi for radiotherapy treatment with some booked up to 2017.

KNH, the country’s foremost public referral facility, charges Sh500 per session of radiotherapy while private hospitals like MP Shah, Aga Khan and Nairobi hospitals levy a fee of about Sh10,000.

The hospital has been under pressure to serve a large number of patients with its few overworked radiotherapy machines, which broke down in March, putting hundreds of lives at risk.

READ: State in talks with private hospitals as KNH cancer machines collapse

Employers and civil servants through their unions have in the past opposed the enhanced contributions.

Workers’ monthly contributions to the fund in April increased from Sh320 up to Sh1,700 based on their pay. This enabled the national health insurer to introduce outpatient services on top of in-patient care that was already running.

Universal health care

But the lack of a deal between the fund and private hospitals has confined contributors to medical care in public hospitals since the rollout of the enhanced scheme on July 1.

The pooling of cash is part of the government’s strategy to achieve universal healthcare, which is a key goal of the country’s Vision 2030 development blueprint.

Several top private hospitals, however, rejected the Sh1,200 during the meeting with NHIF and Ministry of Health officials.

READ: Private hospitals reject Sh1,200 NHIF cash allocation

The Kenya Associations of Hospitals (KAH) — representing 15 top hospitals — maintained the capitation is insufficient and they will not sign up.

KAH members include Nairobi Hospital, Aga Khan, Mater, Kijabe, MP Shah, Gertrude’s and Metropolitan, all of which have rejected the deal.

“Most of our members feel the numbers don’t work for them,” said KAH chairman Kanyenje Gakombe, also the Metropolitan Hospital CEO.

“The risk exposure is very high given that in the capitation model the service provider becomes the insurer,” he said.

Kenyans prefer medical care at the better equipped private hospitals, but most cannot afford the high charges in a country beset with high poverty levels and an unemployment rate of about 40 per cent.

Director of Medical Services Nicholas Muraguri, who sits on the NHIF board, said that the government is racing to win over the top service providers.

“We want to ensure private hospitals become part of this scheme,” said Dr Muraguri, adding that negotiations were ongoing.

Dr Nyaumah has 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.

Patients will, however, part with between Sh100 and Sh200 as a ‘gate-keeping’ fee every time they seek services to deter ‘idlers’ from abusing the scheme.

“Studies have shown that only 48 per cent of contributors to the medical insurance pool seek services annually,” said Dr Nyaumah.

Kenyans on average seek outpatient services three-and-a-half times per year, according to Kaph.

The annual Sh1,200 cover is per person in a household, meaning the scheme will favour homes with many people.

Workers in private firms contributing varying monthly cash under private medical schemes enjoy outpatient cover of up to hundreds of thousands of shillings.

The top hospitals had pointed out that the Sh1,200 cover was not even enough for an appointment with a private doctor, let alone medical care.

Nairobi Hospital, for instance, charges Sh2,000 for outpatients to consult a doctor, MP Shah Sh1,400, Karen Hospital Sh1,800 and Aga Khan University Hospital Sh1,940. Gertrude’s consultation fee stands at Sh1,550.

State-owned KNH’s private wing charges Sh1,000 plus a one-off filing fee of Sh450 for first-time patients.

The public health insurer in June published a list of about 1,128 private and faith-based health service providers that it said had agreed to serve contributors to the enhanced scheme.