Respiratory diseases, pregnancy care top medical cover claims

Respiratory diseases and pregnancy care take up the single largest portion of medical insurance claims in Kenya, a new study showed.

Insurers settled claims worth Sh1.02 billion for treatment of respiratory conditions in 2016 up from Sh749.3 million the previous year, according to the survey commissioned by the Association of Kenya Insurers (AKI).

“Due to the lack of quality data it was hard to pin the most common respiratory diseases. However, tonsillitis, bronchitis and asthma topped the list among children,” Ms Samantha Weya, an actuarial analyst at Zamara, which conducted the study said.

Pregnancy related claims totalled Sh1.04 billion in 2016, rising from Sh935.8 million the previous year.

Respiratory diseases have become one the biggest medical burdens in Kenya on account of rising air pollution.

For instance, pneumonia — a form of acute respiratory infection that affects lungs — is the number one killer of children under the age of five, and accounts for 16 per cent of deaths in Kenya and 18 per cent globally. Last year some 21,854 deaths were linked to pneumonia alone, according to the Economic Survey 2018.

The high prevalence of respiratory diseases has become a pain to medical insurers and households because of the relatively high cost of treatment. The AKI study showed that the average inpatient costs for respiratory diseases per visit was Sh84,614 in 2015 and hit Sh94,485 in 2016.

Though not very common, tuberculosis (TB), however, remains the most cost prohibitive disease based on the average insurance claims of Sh230,587 for inpatient treatment in 2016.

A 2018 national TB patients’ costs survey revealed that a patient visiting public facilities spends up to Sh25,874 while on a six-month treatment programme. The cost is far higher for a patient with the drug resistant TB who pays an average Sh145,110 while on a 20-month long treatment programme.

The head of National Tuberculosis Leprosy and Lung Disease Programme, Maureen Kamene, said that the most economically viable age group -15 to 34 years- is experiencing the highest financial burden of TB treatment.

“Even with the current free diagnosis and treatment policy, the financial burden remains heavy on tuberculosis patients. There is need to consider appropriate steps to lessen the burden of out-of-pocket costs for TB patients and how best to improve service delivery for poor patients,” she said.

She added that there are certain elements of care that are not considered in the free service policy or covered by the National Hospital Insurance Fund (NHIF).

“Some patients loose hearing, suffer kidney failure or experience lung complications and this is not considered to be part of the TB treatment,” she said.

When the costs burden becomes high, she said, patients often differ treatment which leads to build-up of a drug resistant TB that is more expensive to treat for both patient and the government.

Pregnancy-related conditions incur the highest inpatient claims in the medical insurance segment, according to the AKI study, which revealed that the number of women who experience severe and potentially deadly complications while giving birth in hospitals is on the rise.

They make up the highest inpatient admission cases in the country, revealed the report which did not identify reasons for the steady rise in childbirth complications.

“This is because again the industry has not adopted the recommended standards, which would make it possible to just extract the data,” said Ms Weya.

The report shows that based on claims settled in 2016 over one million women were admitted for complications. This was significant rise from the 935,830 women who were admitted over the same in 2015.

HIV /Aids related cost an average of Sh232,530 per inpatient in 2016 and Sh203,849 in 2015. The outpatient average cost per visit was much lower at Sh8,247 and Sh9,151 in 2015 and 2016 respectively.

Overall, the country’s total settled medical insurance claims in 2016 stood at Sh7.401 billion, a 17 per cent rise from Sh6.325 billion in 2015.