Background
Type of scheme | Premium contribution | Population covered |
---|---|---|
Mandatory/automatic | ||
County government schemea [15] | Mandatory/automatic | Employees of County governments that have contract arrangements with the NHIF, their declared spouse and up to 5 children of up to 21 years of age or 25 years if enrolled in fulltime formal education [16] |
Parastatal/ private company schemesa [15] | Mandatory/automatic | Employees of parastatals or private firms that have contract arrangements with NHIF, their declared spouse and up to 5 children of up to 21 years of age or 25 years if enrolled in fulltime formal education [16] |
Mandatory/automatic | Kenya Police Force, Administration police, officers in the Criminal Investigations Department, prisons and other security related officers, their declared spouse and up to 5 children up to 21 years of age or 25 years if enrolled in fulltime formal education [16] | |
Mandatory/automatic | All students in public secondary schools in Kenya | |
National scheme [21] | -Mandatory for formal sector workers, -Voluntary for informal sector workers | Any person who is a resident of the republic of Kenya, who is self-employed or in the informal sector, their declared spouse (s) and children up to the age of 18 years |
Health Insurance Subsidy for the Poor [HISP] Scheme [22] | Mandatory/automatic | Households with orphans and vulnerable children; poor elderly; and/ or persons, persons with disabilities and destitute families |
Linda Mama Free maternity scheme [15] | Mandatory/automatic | All pregnant women who are Kenyan Citizens |
Recent reforms by the NHIF
Type of sector | Monthly salary range 1USD = KES 100) | Monthly premium before the reform | Monthly premium after the reform |
---|---|---|---|
Formal sector | KES 1000–5999 (USD 10–59) | KES 30–120 (USD 0.3–1.2) | KES 150 (USD 1.5) |
KES 6000–7999 (USD 60–79) | KES 140–160 (USD 1.4–1.6) | KES 300 (USD 3) | |
KES 8000–11,999 (USD 80–119) | KES 180–240 (USD 1.8–2.4) | KES 400 (USD 4) | |
KES 12,000–14,999 (USD 120–149) | KES 260–300 (USD 2.6–3) | KES 500 (USD 5) | |
KES 15,000 and above (USD 150 and above) | KES 320 (USD 3.2) | KES 600–1700 (USD 6–17) | |
Informal sector (self-employed) | No salary ranges. | KES 160 (USD 1.6) | KES 500 (USD 5) |
Provider payment method | Healthcare benefit package | Reimbursement rate 1USD = 100 KES | |
---|---|---|---|
Capitation | Outpatient services for national scheme members | KES 1200 (USD 12) per beneficiary per year for basic care facilities a(Level 3 and 4) | |
KES 1400 (USD 14) per beneficiary per year for tertiary care facilities a(Level 5 and 6) | |||
Outpatient services for civil servants (and other enhanced schemes) of lower job group (A-K or its equivalent) | KES 1500 (USD 15) Public hospitals | ||
KES 2850 (USD 28.5) Private hospitals | |||
Case-based payment | Renal dialysis (pre-dialysis, intra-dialysis and post-dialysis care) | KES 9500 (USD 95) per session twice weekly | |
Kidney transplant package- surgical costs and duration of hospitalization | KES 500000 (USD 5000) | ||
Maternity package for National scheme | KES 10000 (USD 100) Normal child birth | ||
KES 30000 (USD 300) Caesarean section | |||
Maternity package for the Free maternity program | KES 5000 (USD 50) for normal child birth or caesarean section | ||
Oncology package- treatment for cancer patients using radiotherapy or chemotherapy case management | Radiotherapy • KES 18000 (USD 180) per week | ||
Chemotherapy • Basic- KES 25000 (USD 250) per cycle • Complex- KES 150000 (USD 1500) per cycle | |||
Surgical package (covers even cancer surgeries) | Major surgeries • KES 80000 (USD 800) for level 3 and 4 facilities • KES 130000 (USD 1300) for level 5 and 6 facilities Minor surgeries • KES 30000 (USD 300) for level 3 and 4 facilities • KES 40000 (USD 400) for level 5 and 6 facilities Specialised surgeries • KES 500000 (USD 5000) | ||
Rehabilitation package (drug and substance abuse) | KES 30000 (USD 300) per year | ||
Fee-for-service | Radiology package | MRI capped at KES 15000 (USD 150) CT scan capped at KES 8000 (USD 80) | |
Dental cover (Enhanced schemes only) [16] | Capped at KES 50000 (USD 500) per annum | ||
Optical cover (Enhanced schemes only) [16] | Capped at KES 40000 (USD 400) per annum | ||
Maternity package for Enhanced schemes | Capped at KES 200000 (USD 2000) | ||
Inpatient care (medical and surgical conditions that require admission) for Enhanced scheme members of higher job groups (L and above or its equivalent) [14] | Job group or its equivalent | Annual limit | |
L | KES 1000000 (USD 10000) | ||
M | KES 1250000 (USD 12500) | ||
N | KES 1500000 (USD 15000) | ||
P | KES 1750000 (USD 17500) | ||
Q | KES 2000000 (USD 20000) | ||
R, S, T | KES 2250000 (USD 22500) | ||
Outpatient care (curative and preventive services) for Enhanced scheme members of higher job groups (L and above or its equivalent) [14] | Job group or its equivalent | Annual limit | |
L | KES 100000 (USD 1000) | ||
M | KES 150000 (USD 1500) | ||
N | KES 200000 (USD 2000) | ||
P | KES 225000 (USD 2250) | ||
Q | KES 250000 (USD 2500) | ||
R, S, T | KES 350000 (USD 3500) | ||
Per diem | Comprehensive inpatient care (Covers medical and surgical conditions that require admission) | KES 1500–4000 (USD 15–40) for public (government) health facilities and, low- cost private facilities and mission hospitals. No co-payments. | |
Non- comprehensive inpatient care (Covers medical and surgical conditions that require admission) | KES 2000–4000 (USD 20–40) for high-end private hospitals. Members pay top up deficit by self-pay or co-insurance | ||
Foreign treatment | KES 1700 (USD 17) per day of hospitalization |
Methods
Study design
Study framework
Study sites
Characteristic | County I | County II | Kenya | |
---|---|---|---|---|
Projected population 2015 | 1,831,800 | 1,107,755 | 44,157,000 | |
Unemployment rate | 19% | 12.5% | 7.4% | |
Poverty rate | 21.8% | 60% | 36.1% | |
Distribution of health facilities by ownership | Private (for-profit and not-for-profit) | 80.5% | 45% | 50.3% |
Public | 19.5% | 55% | 49.7% | |
Doctor: population ratio | 1:17000 | 1:44634 | 1:10000 | |
Immunization coverage | 90% | 53.6% | 80% | |
Percentage of County budget allocated to health (Financial Year) FY 2015/16 | 32% | 22% | Average percentage of county budget allocated to health FY 2015/16 = 23.4% *Target = 35% | |
Percentage of County budget allocated to health FY 2016/17 | 33% | 27% | Average percentage of county budget allocated to health FY 2016/17 = 25.2% |
Characteristic | Hospital A | Hospital B | Hospital C | Hospital D | Hospital E | Hospital F |
---|---|---|---|---|---|---|
Ownership | Public | Public | Public | Public | Private | Private |
Level | Level 4 | Level 4 | Level 5 | Level 5 | Level 4 | Level 4 |
County | County I | County II | County I | County II | County I | County II |
Total annual outpatient attendance workload | 294,352 | 121,661 | 330,022 | 283,677 | 19,153 | 18,539 |
Total annual inpatient admissions | 20,534 | 11,593 | 22,013 | 22,622 | 3366 | 1984 |
Number of beds | 289 | 195 | 457 | 265 | 20 | 36 |
Data collection
National level respondents | |||||
---|---|---|---|---|---|
Male | Female | Total | |||
Ministry of Health | 1 | 1 | |||
NHIF | 1 | 1 | 2 | ||
Development partners | 3 | 1 | 4 | ||
Total national level participants | 5 | 2 | 7 | ||
County I | County II | Number | |||
County level participants | Male | Female | Male | Female | Total |
County health department officials (County director of health, County nursing officers, county clinical officers) | 1 | 1 | 1 | 2 | 5 |
NHIF branch officials | 2 | 1 | 1 | 1 | 5 |
Public hospital managers (Medical superintendent, Nursing services managers, Pharmacist in-charge, Clinical officer in-charge) | 1 | 2 | 2 | 2 | 7 |
Private hospital managers (Medical managers, Nursing services managers) | 1 | 1 | – | 1 | 3 |
Public hospital frontline health workers (Clinical officers, Nurses) | 1 | 1 | 1 | 1 | 4 |
Private hospital frontline health workers (Clinical officers, Nurses, pharmacists) | 1 | 2 | 1 | 2 | 6 |
Public hospital NHIF billing clerks | – | 1 | 1 | – | 2 |
Private hospital accounts staff | 1 | – | 1 | 2 | |
Total county level participants | 8 | 9 | 7 | 10 | 34 |
Attribute | County I | County II | ||
---|---|---|---|---|
FGD I | FGD II | FGD I | FGD II | |
Gender | Male (n) = 6 | Male (n) = 7 | Male (n) =4 | Male (n) = 5 |
Female (n) = 6 | Female (n) = 9 | Female (n) = 6 | Female (n) = 8 | |
Age range | 28–57 | 31–65 | 25–53 | 33–67 |
Employment status | Formal sector (n) = 9 | Formal sector (n) =12 | Formal sector (n) = 8 | Formal sector (n) = 10 |
Informal sector (n) = 3 | Informal sector (n) = 4 | Informal sector (n) = 2 | Informal sector (n) = 3 | |
Total FGD participants (n = 51) | County I (n) = 28 | County II (n) = 23 |
National statutory documents | The Constitution of Kenya |
---|---|
Vision 2030 | |
Kenya Household Health Expenditure and Utilisation Survey. | |
Kenya Service Availability and Readiness Assessment Mapping (SARAM) Report. | |
Mini-service availability and readiness assessment (MINI-SARA) 2016 survey report | |
National Hospital Insurance Fund Act | |
NHIF documents | Annual Management report 2015/16 |
Annual Management report 2016/17 | |
Explanation of the benefit package for the National Scheme. | |
NHIF report on availability and quality of NHIF services at the healthcare provider and NHIF offices | |
Comprehensive medical insurance scheme for civil servants & disciplined services hand book | |
Handbook For Provision Of Comprehensive Medical Cover, Group Life Insurance and Last Expense Cover to Civil Servants | |
Enhanced Benefits Medical Scheme Book | |
National Police service & Kenya Prisons Service Comprehensive Medical Cover & Last Expense Handbook |
Data management and analysis
Results
NHIF reform 1: upward revision of premium contribution rates
Purchaser-citizen relationship
These population groups were less likely to be aware of the new premium rates. They continued making premium payments using old rates which limited their access to the new benefit entitlements since they were no longer considered active contributors.“Those people in remote areas have not been reached especially where NHIF offices cover a large area. They cannot give that information immediately because it takes time for them to go and access those people and give that information” Male participant, NHIF, County I
“At the village, some people are not aware at all of the increased premium rates and how they operate. It is only when they go to the hospital that they really get shocked that they cannot get services and they are being told to go to the NHIF office.” Male Participant, FGD I, County II
“In the village, there are youths who have finished school without formal employment but their age surpasses the required age for the cover under their parents. As a parent getting that 500 shillings to pay for him or her is a problem. They are not covered.” Female participant, FGD II, County II
FGD participants working in the informal sector cited the higher premium rates as a cause of attrition as they could no longer afford them. Document reviews showed that while total NHIF membership had grown from 4 million in 2012 to 6.8 million in 2017, only 48% of these members were active contributors [15]. Active contributors were fewer in the informal sector than formal sector. Only 27% of informal sector members had active membership compared to 65% of the formal sector members as of June 2017 [15].“There are quite a number of people who are not taken care of like the disabled group who cannot afford to pay for the national scheme. And where do they fall? They also become sick. Unless someone pays the money for them” Male manager, private hospital F
“Now we are required to pay 500 shillings. This is too much money for poor people like me. I have nowhere to get that kind of money. I felt that I had no option but to abandon my card” Female participant, FGD II, County I
“NHIF is for those who can afford” Male participant, Development partner, National-level
NHIF reforms 2: introduction of new benefit packages
Purchaser-citizen relationship
Some FGD members and development partners felt that knowledge and awareness of the new reforms by certain population groups was limited by: 1) the use of complex language (such as medical terms) to describe the services offered, 2) vagueness of the benefit package where services were presented in broad categories making it difficult for users to know what specific services they are entitled to, 3) limited geographical coverage of communication and sensitization campaigns and, 4) limited knowledge and awareness among some healthcare providers who were gatekeepers for access to these services.“They are not fully aware because some people will say ‘I have registered under NHIF’ but they do not know there is something called capitation and there are restrictions with capitation. You only go where you are capitated. They must be told categorically that with NHIF, they and their dependents must be capitated somewhere to access the outpatient services. They also do not know that for inpatient care, they can go anywhere. Even those who are capitated in this hospital think that they must come for admission in this hospital not knowing that they can also be admitted anywhere else as long as they have the cover and that they meet the category of the hospital.” Male manager, Hospital F, County II
“There is a problem in NHIF. They have not done communication to all health facilities that we have registered with. Sometimes you are chased away and they do not normally honour us” Male participant, FGD I, County II
Frontline providers and FGD participants also felt that the services offered under the new benefit packages addressed prevailing disease burden.“We knew the needs of our members. Some of the biggest health problems were oncology and surgeries. There was also this study on non-communicable diseases that was done by the Ministry that showed that cancers, diabetes and hypertension were on the rise. We also considered information from our data, and from complaints and requests received from our members through their own groups like the Kidney care group which pushed us to include dialysis sessions.” Female participant, NHIF, National level
“Yes, people’s needs are covered. Majority of our patients come here with typhoid and malaria which are covered. If somebody has hernia or needs a caesarean section, surgery can be done. Normal deliveries are also covered. If somebody needs laboratory tests, they can be done. Most of the important things that the patients need are covered.” Female frontline provider, private hospital F
“The advantage lies in the fact that we can now get treatment for life threatening ailments such as cancer, cardiovascular disease, diabetes and others” Male participant, FGD I, County I
“Late last year, my mother was hospitalized at the district hospital. We bought medicines daily. When we went to collect the prescribed medicines in the pharmacy, there were some classifications. There were those who were given medicines but told to pay more and those with an enhanced scheme who got medicines for free. This disparity brought a lot of problems because you see your next neighbour, who is a patient like you, being served while you cannot get the same medicines without buying them.” Female participant, FGD I, County II
Government- purchaser relationship
“There is a shortage of doctors and specialists like oncologists. Public hospitals are also overstretched and they do not have tests such as CT Scan or ultrasound which forces you to seek care in a private hospital. So, in as much as you have an NHIF card, it is not very useful in a public hospital because you will not get the services.” Female participant, FGD II, County I
Purchaser- provider relationship
Document review showed that private health facilities (both private-for-profit and private-not-for-profit) accounted for 75.5 and 56.9% of all health facilities contracted by NHIF in County I and II, respectively. While this finding may be expected for county I which has a higher proportion of private health facilities, it was not expected for county II which had a higher proportion of public than private health facilities. NHIF officials felt that this resulted from a lack of initiative by government health facilities to seek contracts with NHIF as well as staff shortages within NHIF to do active follow up on the same.“NHIF historically was only covering hospitals and we know that in terms of facility density, most of the facilities in rural areas are primary level so already there is a disproportion there. Even with the hospitals, it was a specific set of them. Not all hospitals were NHIF accredited. Now they have started going to the primary level facilities but not all of them have been brought on board. Therefore, access to care in rural areas is much lower than in urban centres and we know that the larger proportion of our population lives in rural areas.” Female participant, Development partner, National-level
FGD participants felt that the pro-private distribution of contracted health facilities within their counties was discriminatory because it was mainly civil servants who could access services in these facilities. Access to the health facilities varied by type of scheme. Members of the national scheme accessed services from contracted public facilities or low-cost private hospitals. Civil servants and members of enhanced schemes could access both contracted public and private health facilities including high cost private hospitals [14, 16, 18]. In addition, FGD participants felt that services offered in private-for-profit hospitals were more expensive than in the public hospitals which put them at risk of making additional OOP payments or depleting the limits capped on specialized services by the NHIF.“Private hospitals are more. It is only when we started the government initiative of Linda mama [free maternity programme] that we brought in so many government health facilities. However, it is not easy to bring them on board because they are not motivated even to come here. It is us to communicate with them, call them for letters or deliver those letters to them which is not easy. But for private facilities, it is a self-initiative.” Female participant, NHIF branch official, County II
“I took my son to a private hospital where he was diagnosed with ulcers caused by H. pylori. His medicines cost almost 14,000 shillings. I panicked because I knew we would exhaust our yearly allocations. I also developed the same problem but I went to the Level 5 public hospital. The treatment did not cost me more than 800 shillings. I even argued with the doctor about this. How comes my son’s H. pylori kits cost 14,000 in the private hospital but it cost me less than a thousand shillings in a public hospital? This is very bad” Male participant, FGD I, County I
NHIF reforms 3: introduction of new provider payment methods and rates
Purchaser- provider relationship
The perceived inadequacy of capitation incentivized some public providers to ask patients, particularly those with chronic illness, to buy medication elsewhere. For private providers, it incentivised them to either undertreat, charge co-payments, refer to other accredited health facilities or, admit NHIF beneficiaries who would have otherwise just required outpatient care. Media reports indicated that major private hospitals had altogether rejected capitation which further limited access to care for members of the national scheme [43, 44]. Healthcare providers did not understand that capitation refers to a fixed amount of money paid per patient per unit of time based on population level data on costs and average utilization of services.“I remember being in those discussions a while back where we were asking NHIF officials what the basis for the capitation was. They kept saying that they had done some costing studies but they never shared any of that information. We wanted to know the basis of going from 2,850 shillings for the civil servants to 1,200 shillings for the national scheme. I mean at least for the reimbursements for the special packages they could go and observe what the market rates are, right?” Female participant, Development partner, National-level
“For fee-for-service, we can do more laboratory tests compared to the national scheme. For national scheme, I am told not to send them to the laboratory for many investigations because their capitation money will be exhausted just from consultation without even medication. So, I am forced to treat clinically yet some patients require a conclusive test that will help us manage them well. Yes, we are forced to cut on cost.” Male frontline provider, private hospital F
NHIF beneficiaries seeking care in private facilities felt that the delayed reimbursements by NHIF had incentivized providers to: 1) introduce co-payments, 2) deny or ration services offered to them, 3) treat them with less respect, or 4) expose them to longer waiting times than patients with other forms of insurance or cash paying patients.“So even claims that we took two months ago have not been reimbursed because they are down financially. The NHIF informed us that they do not have money” Male manager, public hospital C, County II
“Private hospitals do not treat us with respect. There is even a notice, “do not give these medicines to NHIF patients” in their pharmacy. If you peep inside, you will see the label. It is as if you are a second-class citizen from those with other medical covers who are treated superiorly.” Female participant, FGD II, County II
“It is like torture there because those who have cash are treated quickly. So, at times when I go to the hospital, I feel that it is better for me to use cash than to use my NHIF card so that I can get treatment faster.” Female participant, FGD II, County I
Several system weaknesses had led to this. First, the self-assessment process- whereby health facilities could assess their own structural capacity prior to contracting [49]- created a loophole for fraudulent behaviour. County officials reported that some providers exaggerated their structural capacity (e.g. beds, medical equipment and theatre rooms) during this process to obtain a higher level of reimbursements from per diem and case-based payments for inpatient and specialised services respectively.“There has been massive fraud. Some of the providers are working with people at the NHIF to defraud NHIF and one of the areas they have been taking advantage of is the issue of major surgery and minor surgery. Most hospitals have been converting the minor surgeries to major surgeries so that they can get higher reimbursement. The fraud has been there but it has become a big issue since the introduction of those specialised packages” Male participant, Development partner, national-level
Secondly, the limited number of NHIF officials (claims and benefits officers, and quality assurance officers) undermined frequent surveillance of health facilities. Their limited number coupled with the manual claim confirmation and reimbursement process and increased workload, created a barrier to a fast and efficient process of confirming the authenticity of claims.“When we looked at the facility, they did not have a theatre yet NHIF said they were making claims for operations done. So how did they do the operations without the theatre? It was questionable. There was a room that they said was a theatre but we know that a theatre is not just a room. The facility did not have all the things required to make a theatre” Male county level manager, County I
Thirdly, weak identification processes for NHIF beneficiaries seeking care incentivized some beneficiaries to engage in fraudulent behaviour such as: 1) use of false identity cards to obtain care, 2) hiring out of the NHIF cards to those without but who needed access to care, 3) use of NHIF cards to illegally obtain medication for people who were not members of the scheme or, 4) impersonation.“Surveillance should be done at least twice a week but we face challenges. There are many contracted health facilities and fewer quality officers so it is not easy for us to reach all of them. So now we do what we call smart surveillance- where we visit health facilities with high claim notifications” Female NHIF branch official, County II
NHIF officials and media reports indicated that the NHIF was however implementing various strategies to curb fraudulent activities such as: online notifications for inpatient admissions, centralised authorisation (letters of undertaking) for surgical procedures and specialised imaging studies [50] and, introduction of biometrics for identification of beneficiaries.“The challenge we have in government (public) facilities is actually that of fraud through impersonation where one gives their card to their sibling to pass as them in order to use the card to access services” Male NHIF branch official, County I
“We are going the biometric way. We assessed and provided some health facilities with the gadgets and software. Once we have all the biometric features for the members, we will reduce cases of impersonation and cases of patients not being in the wards when they were supposedly admitted.” Male NHIF branch official, County II