The National Hospital Insurance Fund (NHIF) is a critical player in the country’s efforts to achieve affordable and quality healthcare for all, a role that will increase focus on the State insurer’s services.
NHIF CEO Peter Kamunyo spoke to the Business Daily on the efforts to restore trust in the national insurer, new benefit packages, role in the universal health coverage (UHC) and the fight against fraud that has bled the institution billions of shillings.
HOW WOULD YOU DESCRIBE THE STATE OF THE NHIF TODAY?
We are making baby steps towards restoring 100 percent trust. We are not there yet, but we are creating systems and processes to make it happen. For example, we are curbing fraud and paying on time. For example, we are now paying within 14-21 days for current claims, though the contract says up to 90 days and this has been made possible by the e-claims platform.
The last three years have been about reforms at the NHIF. This journey has two intentions; to make the NHIF a strategic purchaser of healthcare services and products and to be the vehicle to get Kenya to universal healthcare.
THE NHIF ACT WAS AMENDED LAST YEAR, MAKING MEMBERSHIP COMPULSORY AS PART OF THE REMODELLED UHC. WHAT RATES WE ARE LOOKING AT AS MEMBERS?
Yes, we are still looking at the Sh6,000 per household annually under the remodelled cover, or Sh17 per day. But as we move forward this is something we will look at keenly. We have not reviewed rates for the past seven years and throughout this period medical inflation has been increasing.
But instead of increasing contributions for the few people, we must make sure that more people are contributing and this has been made possible through the amended Act.
To sustain the scheme we need to grow the pool. With the operationalisation of the Act, we shall know if it fits. If it does not, we will be bound to look at our rates.
REGULATIONS TO OPERATIONALISE THE ACT WERE OPENED FOR PUBLIC PARTICIPATION IN MARCH. WHERE ARE WE EXACTLY WITH THIS PROCESS?
We drafted regulations and opened them up for public participation in March, then we forwarded them to the National Assembly Committee on Delegated Legislation. Unfortunately, Parliament went on a long recess before it could approve them.
We are now looking at the 13th Parliament after the elections to approve them. As the NHIF we hope that these regulations will be a top priority for the new Parliament because this is key to the rollout of universal healthcare.
WHAT ARE THE MAJOR WINS FOR THE NHIF FROM THE AMENDMENTS?
That big bit of the NHIF Act amendment is that we were moved from National Hospital Insurance Fund to National Health Insurance Fund. This means we can now contract other healthcare providers, we can contract consultants and laboratories then directly reimburse them.
Before the amendments, we could only reimburse hospitals, and that has been a problem. Why don’t we have consultants who charge less? We can negotiate with them and get lower rates.
Now we will be more creative in cost containment, adding quality and value to our members and this will be done through the Pharmacy Benefits Management (PBM).
THE COST OF LIVING HAS BEEN ON THE INCREASE AND SO HAVE MEDICAL BILLS. HOW IS THE NHIF ADJUSTING TO THIS?
We are paying a lot more in claims and it is something we need to look at. That is why we also need everybody in the basket through the compulsory listing.
We have three ways of addressing this — a review of our rates at least to match inflation and rolling out a pharmacy benefits management where we will be able to sort out the issue of the inputs. Remember pharmaceuticals account for between 40-70 percent of the total cost.
We need to make sure that people get the benefits they pay for and that the NHIF remains sustainable. We do not get money from the Exchequer, we cannot get funds from the Treasury but we will need to amend the law to change this.
LAST YEAR, THERE WAS A PLAN TO CUT THE BENEFITS PACKAGE AS PART OF REDUCING THE CLAIMS PAID BY THE NHIF BY ABOUT SH2 BILLION ANNUALLY. WHAT BECAME OF THAT PLAN?
We did not cut the benefits, this would have had a serious impact on patients like those who rely on the NHIF for renal dialysis. We retained the package and even went further to expand the benefits under the new contracts signed with health facilities last week.
For ailments like cancer, we have introduced more of investigation and early detection and now patients are getting mammography and fluoroscopy. We have also enhanced other diagnostics like for people with epilepsy, we have introduced electrocardiogram (ECG) as well — four to six sessions, at about Sh100,000 per session.
In the past, you were stuck to the four. We had a high number of people who were missing out because the sessions were four.
ADVERSE SELECTION HAS BEEN A MAJOR PROBLEM FOR NHIF. HOW ARE YOU ADDRESSING IT?
Yes, this has been one of the biggest problems the NHIF faces. The way to cure adverse selection is to make sure everybody is on board and this has been made possible by the Act. This is one of the biggest wins from the Act because without curing adverse selection, the NHIF will not survive in the long run.
Every day we keep seeing people who pay or join the scheme because they need treatment but through compulsory membership then this will become unnecessary. Remember all must pay and then the government will pay the rates for the vulnerable people.
HOW BIG WAS THE IMPACT OF THE CORONAVIRUS-INDUCED ECONOMIC HARDSHIPS ON THE NHIF?
Interestingly during Covid, we had more voluntary contributors than we have ever had before. People realised the importance of having medical cover.
We have a significant number who joined but we also noted there were companies that struggled, that shut down. Now we are seeing recovery and some are coming back. We are in the process of removing the ones (companies) that folded.
BESIDES THE SHIFT TO BIOMETRIC REGISTRATION, WHAT ELSE IS THE NHIF DOING TO CURB FRAUD AND THE RAMPANT PROBLEM OF FICTITIOUS CLAIMS?
To access any service now, you must use biometrics. There is also a big shift to e-claim and registration of mobile numbers. Members are now registering their mobile numbers with the NHIF and this allows one to get notifications of authorisations. This has helped us curb fraud because members can call our customer care in case they get notifications.
