The Road to UHC in Kenya: Inside NHIF Reforms Jan 11, 2016

The Road to UHC in Kenya: Inside NHIF Reforms

With a rapidly growing population of over 40 million, Kenya is the 7th largest country in Africa. In recent years, the country has undergone significant health reforms, implemented largely by the National Hospital Insurance Fund (NHIF), Kenya’s primary provider of health insurance with a mandate to provide all Kenyans with quality and affordable health services.

To learn more about the NHIF’s operations and key reforms to-date, including the roll out of new contribution rates, we reached out to long time JLN member Joseph Githinji, NHIF’s Assistant Manager for Benefits and Product Development. In this interview, Mr. Githinji discusses the strengths and weaknesses of the NHIF, as well as the passage of  new guidelines that expands coverage to outpatient services and increases the annual premium for the first time since the launch of the scheme.

Mr. Githinji has been an active member of the JLN since 2010. He has participated in a variety of joint learning activities including the quality initiative, the Costing Collaborative, and most recently the Data Analytics for Monitoring Provider Payment Mechanisms collaborative.

JLN: What do you think are the strengths of Kenya’s National Hospital Insurance Scheme?

JG: The NHIF has many strengths. The scheme is anchored by the NHIF Act of 1998 (revised 2014), which ensures sustainability, as all employed residents will pay their subscriptions through deductions directly to the Fund. Another strength is governance and accountability. There is a board of management selected from the major stakeholders with a strong government representation. The NHIF also has a strong relationship with government and development partners. There are several collaborations taking place to improve the Fund. 

Moreover, there is a wide health provider network of accredited facilities. There are approximately 1600 facilities that members can access across the country. All the facilities are required to have quality improvement programs in place. The NHIF also has well-established operating systems with automated processes, and a network of competent & motivated staff located at 72 service points throughout the country to serve members, employers and healthcare providers.  

JLN: What are the weaknesses of the NHIF?

JG: Some weaknesses include: inadequate premiums to allow for deeper coverage; limited benefit packages, specialized services are not covered; ICT System downtime & inadequate integration with other systems for ease of doing business; communications strategy; inadequate entrenchment of the risk management in carrying out many of the procedures; inadequate, unenforced contract management system; unenforced performance management system; and weak implementation of accreditation management framework.

JLN: The NHIF has seen the passage of a number of reforms in recent years. Can you describe the most notable reforms, the purpose of these reforms, and the how the NHIF aims to implement?

JG: Yes, there have been several reforms. This includes the introduction of contracts with healthcare providers, which mandate that all patients receive high-quality health care. Other reforms include: internal staff restructuring to ensure optimal employee performance; and increase of contributions so as to increase the depth of the benefit package.

JLN: The most recent reform you speak about involved increasing the contribution rates for employees in the formal sector for the first time since the scheme’s launch, as well as expanding coverage to outpatient services. What impact will these two reforms have on the scheme?

JG: The greatest impact is that there will be more funding available to increase the depth of the benefit package, since the majority of the enrollees are in the formal sector where contribution is mandatory. This increase will provide better services and an enhanced benefit package for beneficiaries and a higher income for healthcare providers. There is consideration of having a chronic care package to members.

The expansion of coverage to outpatient services will go a long way toward reducing out-of-pocket payments for the more vulnerable populations. We will also need to revise the method of payment since outpatient services will be paid under capitation.

JLN: Do you think these reforms will help the NHIF expand coverage to reach the new sustainable development goal target of 100 percent coverage?

JG: I believe this is a big step forward. The current Government has pledged to provide healthcare for all. NHIF is, therefore, a key vehicle to deliver healthcare. The increased contributions, which will provide out-patient and in-patient coverage, will be a great piloting ground towards the goal of achieving 100 percent coverage.

JLN: What impact will the increased contribution rates have on the NHIF’s operations? What will the NHIF be able to achieve that was unattainable before the contribution increase?

JG: The main focus of the contribution increase was to improve the depth of the benefit package, in order to offer both in-and outpatient care for members. The outpatient benefits are expected to increase retention and enrollment of the informal sector. In addition, there has been concern that the pay-out ratio was not favorable due to the increasing administrative costs. The new contributions mean an improved payout ratio since the administrative costs are not expected to significantly rise.

JLN: What outpatient services will be covered and how will the NHIF work with private providers to deliver the new package of services?

JG: The services to be offered will include both preventive and curative elements, including: diagnosis and treatment of common ailments; prescribed basic laboratory and x-ray investigation services; prescribed drug administration and dispensing; management of chronic ailments (HIV/AIDS, diabetes, asthma, Hypertension, cancer); and many more.

NHIF Act allows accreditation of  all facilities— private and government—so long as they meet the set criteria. Nearly two-thirds of our providers are private (for-profit and not-for-profit faith-based organizations). The NHIF will study the delivery of services by health providers and will consider practical partnerships with private providers including, stand alone laboratories, specialized care centers, and even pharmaceutical companies that provide cost-effective drugs for chronic non-communicable diseases.