What they’re not telling you about NHIF

Last Saturday more than 200 medical specialists and general practitioners gathered for a meeting in Nairobi under the auspices of the Kenya Medical Association.

Soon, a debate ensued about why universal healthcare coverage in Kenya is doomed. The discussion raised one fundamental question: will the proposed National Hospital Insurance Fund (NHIF) medical cover meet members’ expectations?

You have probably already realised that although you started paying the enhanced premiums three months ago, you do not know what the NHIF cover will pay for and what it will not.   

Regarding outpatient cover, NHIF proposes to pay hospitals Sh740 for an outpatient visit, which is too little considering that a recent cost-of-care report by the Institute for Health Metrics and Evaluation found that the average cost of a single outpatient visit at a public hospital in Kenya is Sh3,000.

Moreover, the report points out that the average annual cost of treating a patient with a chronic illness (such as diabetes, hypertension, HIV, and heart disease) who, due to the nature of their illness must visit a doctor regularly, is Sh25,000, which is 10 times higher than what NHIF is willing to pay.

It is a sure bet that the irreconcilable deficit will automatically result in unethical and intentional rationing of essential care under the cover.

Similarly, NHIF’s claim that it will offer comprehensive inpatient services and that members are at liberty to attend any hospital should be taken with a grain of salt.

It is now emerging that the fund does not intend to raise the daily inpatient rebates, currently set at between Sh400 to Sh2,400, despite raising members’ premiums five-fold.

The decision not to revise inpatient rebate rates is counter to current local evidence. In respect to inpatient costs, two things are known: First, inpatient expenditure on treatment for cancer, injuries, and other surgical procedures pushes about 1.48 million Kenyans into poverty every year.

Second, the actual average cost of these essential surgical procedures at public hospitals is Sh20,000, which is 15 times higher than the average NHIF reimbursement rate to these hospitals. It could be assumed that it is for this reason that the government has invested Sh38 billion to lease cancer diagnostic machines and other equipment.

It is disheartening that the State’s insurance will not pay the costs of treatment. Since cancer treatment and surgical procedures attract a fee that is at least five times higher in the private sector, most Kenyans will have to pay for them.

Another cause for worry is that NHIF’s history is dogged by inefficiency. In last year’s financial statements, payables outstripped available revenue by a huge margin, yet there is no legal provision on how potential budget deficits would be covered. The dynamics of healthcare provision under devolution is another challenge.

There is every possibility that public hospitals will catch the “Pumwani hospital fever” that is exemplified by lack of management autonomy, little emphasis on quality of care, and poor priority setting.

All these issues point to a scheme that is not tuned to provide financial risk protection. Clearly, the management seems to be clinging to the hope that these conspicuous dysfunctions will not be noticed.

Dr Kihuba is a health systems researcher with SIRCLE.  [email protected]