NHIF halts plans to restrict private hospitals cover

The National Hospital Insurance fund building in Nairobi in this photo taken on March 27, 2022. PHOTO | LUCY WANJIRU | NMG

The National Hospital Insurance Fund (NHIF) has backtracked on a bid to stop paying for treatment of chronic illnesses like cancer at private hospitals.

The NHIF has committed to dropping the proposal to limit funding treatment of chronic illnesses in public hospitals following a petition from the workers’ lobby, Central Organisation of Trade Unions (COTU).

The proposal in the NHIF (Claims and Benefits) Regulations 2022 was aimed at easing the insurer from the burden that comes with expensive private hospitals, but it would have hurt members since they would be forced to deal with congestion and the lack of facilities in the public hospitals.

The State-owned insurer now says it will amend the regulations to provide a list of contracted private hospitals where members with chronic illnesses will seek treatment.

“The regulation on Benefits and Claim 6(1) to be reviewed to provide that the board will provide a list of both private and government healthcare providers that offer services for chronic illness from which a patient will choose the healthcare provider to access the service from,” said the insurer.

The proposed regulations would have hurt top private health facilities like Nairobi Hospital and Mater Hospitals that have been earning billions of shilling from the NHIF to ease the burden of treating chronic illnesses on Kenyatta National Hospital.

The NHIF says chronic illnesses include cardiovascular disease, cancer, diabetes, obesity, respiratory disease, mental health condition, neurological condition, hemoglobinopathies, haemophilia, bleeding disorder and epilepsy.

Others are neurological disorders, autoimmune diseases, renal disease, skin conditions, degenerative joint and spine conditions, osteoporosis or oral disease and condition that require ongoing medical attention.

Private hospitals have over the years enjoyed increasing business from the NHIF for the treatment of chronic illnesses due to the congestion at public hospitals.

There has been an increase in chronic diseases that the Ministry of Health says present one of the biggest burdens to the health systems.

Urban lifestyles

The surge in chronic diseases has been linked to lifestyle mainly among middle-class Kenyans, forcing them to spend more on treatment. The diseases are linked to unhealthy eating habits and sedentary urban lifestyles with no regular workouts.

The proposal to bar NHIF members from seeking treatment for chronic illnesses at private hospitals would have eased the claims burden on the State-owned insurer at a time the insurer is set to provide insurance to all Kenyans aged above 18.

The scheme has for years grappled with a high claims ratio that eats more than 90 percent of the premiums collected. For example, the insurer paid Sh54 billion as claims in the year ended June 2021, representing 91 percent of the 61.5 billion that it collected as premiums.

The NHIF more than doubled the number of surgical procedures it covers for its members, expanded oncology benefits for cancer patients and increased the reimbursement rates for healthcare facilities by 12 percent further adding to the claims burden.

NHIFmembership will be compulsory for all Kenyans aged above 18 under the remodelled universal healthcare following changes to the NHIF Act.

NHIF estimates that it will rake in Sh81 billion annually from the compulsory membership but does not disclose the anticipated medical costs that it will have to foot per year given that claims are set to increase due to more beneficiaries.

PAYE Tax Calculator

Note: The results are not exact but very close to the actual.