The proposed amendments to the NHIF Act have elicited varying reactions with some stakeholders, notably the Central Organisation of Trade Unions (Cotu) and the Association of Kenya Insurers (AKI), voicing their opposition.
However, the proposed amendments are timely and, if well implemented, will offer immense benefits to Kenyans by promoting Universal Health Coverage (UHC).
First, the amendments will expand the range of healthcare service providers available for Kenyans to access services. Currently, the NHIF Act only recognises hospitals, and “hospital type” healthcare facilities (maternity/nursing homes and clinics), that offer inpatient and outpatient healthcare services.
The NHIF will not pay for services provided by a stand-alone laboratory or an individual doctor’s practice because these do not meet the definition of hospital prescribed in the current law.
The proposed amendments broaden the definition of a healthcare services provider to include duly registered healthcare professionals, and those that offer diagnostic services, opening the door to private individual practices and standalone laboratory and diagnostic imaging services for instance.
This is a win for the public since they will have wider options when seeking care. It is also a win for the healthcare professionals fraternity since it has widened the opportunity for their members in individual practice to become service providers under the NHIF.
Second, the proposed amendments will expand the range of services that Kenyans have access to from a narrow focus on treatment to a broader one on health prevention and promotion. It is a well-known fact that prevention is better than cure, and that preventive and promotive services, including for instance immunisation and family planning services are more cost-effective compared to treatment.
However, the NHIF has historically ignored preventive and promotive services and instead prioritised treatment. The proposed amendments promise to right this wrong, to the benefit of Kenyans, by opening the door for a revision of the NHIF service package to include critical preventive and promotive services such as screening for cancer and contraceptive services.
Third, the proposal that private health insurers incur the first charge of medical bills before the NHIF will promote equity which is a foundation for UHC. Currently, private insurers require that the NHIF incur the first charge of medical bills, with the private cover paying the balance. This practice is inequitable and amounts to robbing the poor to pay for the healthcare services of the rich for the following reason.
Only about one percent of Kenyans have private health insurance. Those with private health insurance also happen to be the richer in society given that private health insurance is expensive. About 20 percent of the Kenyan population is covered by the NHIF.
The one percent that have private health insurance is part of the 20 percent that is covered by the NHIF but is clearly the minority, with most people covered by the NHIF not having private health insurance.
Since NHIF contributions are pooled, the current practice results in contributions for NHIF members without private health insurance (the poorer member) being used to pay for healthcare bills of NHIF members with private health insurance (the richer members).
The proposed amendment will see the rich paying for the poor. This is more in line with the principles of equitable health systems. One would expect that a workers union whose majority members do not have private health insurance would be supportive of such a move.
Fourth, the amendments will strengthen the governance and accountability of the NHIF. The NHIF has faced challenges including weak leadership, corruption, and poor accountability to the public. The proposed amendments prescribe, for the first time, minimum qualifications and experience for the NHIF chief executive.
While this is not a silver bullet for NHIF’s leadership problems, it ensures that at the very least, the person in charge has the competencies. The amendments also propose that NHIF provide statements to its members. Further, the proposal to increase fines on individuals and healthcare facilities that commit fraud from a measly Sh500,000 to Sh10 million is likely to discourage and reduce cases of fraud that cost the NHIF millions if not billions of shillings annually.
Healthcare facilities that commit fraud now face deletion from the register of contracted health care providers.
Lastly, the proposal for employers to match employer contributions to the NHIF is a game-changer that will boost resource mobilisation and sustainability for UHC.
The goal of using the NHIF as a vehicle for UHC by scaling up its membership to cover every Kenyan cannot be achieved by relying on member contributions alone.
Such reliance is unsustainable and at odds with international best practice and evidence. Why? 83 percent of Kenyans in employment are in the informal sector, and 36 percent of Kenyans are poor.
Reliance on contributions alone effectively excludes the poor and those in the informal sector and effectively buries Kenya’s UHC dream. Employer matching of contributions will mobilise additional funds.
Employer matching is not an outlandish idea. Established social health insurance schemes in Europe, including Austria, Belgium, France, Germany, Luxemburg, and the Netherlands, and Tanzania, Gabon, and Sudan have social health insurance schemes where employers match employee contributions.
The writer is Director, KEMRI-Wellcome Trust Nairobi Programme and professor of Health Economics, University of Oxford email [email protected]