Background
Methods
Data collection
National reports and strategic proposals
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NSHI strategy: Comments and Suggestions of the Joint WHO/GTZ mission on Social Health Insurance in Kenya (1st Mission) WHO/GTZ, June, 2003 | |
NSHI strategy: Comments and Suggestions of the Joint WHO/GTZ mission on Social Health Insurance in Kenya (2nd mission) WHO/GTZ August, 2003 | |
NSHI strategy: Key findings and prerequisites for implementation (3rd mission) WHO/GTZ/KfW Germany December, 2003 | |
NSHI strategy: Progress review and recommendations (4th Mission) WHO/GTZ/DFID January 2004 | |
Progress review of the initial implementation stage and recommendations (5th mission) Joint WHO – GTZ – DFID – ILO Mission to Kenya 29th March to 2nd April 2004 | |
Sessional paper No 2 on National Social Health Insurance in Kenya in Kenya May 2004 | |
The National Social Health Insurance Fund Bill, 2004 | |
Presentation by Amit Thakker CEO 2004. Avenue group in the informal session with stakeholders | |
Financial projections and future bilateral/multilateral cooperation (6th Mission) WHO/GTZ mission_21st to 26th June, 2004 | |
Carrin et al 2007 health financing reform in Kenya-assessing the social health insurance proposal | |
IPAR 2005, Social Health Insurance Scheme for All Kenyans: Opportunities and Sustainability Potential IPAR policy Brief Volume11, Issue 2, 2005 | |
WHO 2006: Health financing reform in Kenya: assessing the social health insurance proposal | |
MOPHS & MOMS March 2009, Towards a Health Financing Strategy for Kenya | |
Nzoya Munguti, 2006, Review of Social Health Insurance in Kenya November 2006 | |
Documents from International meetings
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Opening of the International GTZ-ILO-WHO Conference on Social Health Insurance in Developing Countries Berlin, 5, 2005 | |
Social health insurance and its role in economic development and poverty reduction Inaugural Address by Mr. David Fuentes-Montero, Minister of Finance from the Republic of Costa Rica, in Central America | |
The inclusion of the poor in social health insurance framework: the strategies applied in viet nam By Dr Tran Van Tien during The international Conference on Social Health Insurance in Developing Countries Berlin 5;– 7 December, 2005 | |
International Conference on Social Health Insurance in Developing Countries by Julio Frenk et al, 2005 | |
GTZ-ILO–WHO International Conference “Social Health Insurance in Developing Countries” Trends in health sector reform in Latin America in the 90’s and challenges for social protection in health in the 21st century by Eduardo Levcovitz | |
Social health insurance: Social security and HIV/AIDS The experience of the National Social Security Fund by David Lambert Tumwesigye, Lusaka, Zambia, 9-12 August 2005 | |
Newspaper cuttings
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Health Matters: Plan to increase deductions by insurer continue to draw anger from workers: Daily Nation 17th Aug, 2010 pg 11: “Civil servants reject NHIF dues | |
Growing pains: Even as Government improves healthcare, questions emerge over financing Daily nation 17th Aug, 2010 smart company pg 10: “The poor will finance the rich in the new medical plan | |
Medical Care: Sunday nation 20th June 2010 pg 4: hospital fund contribution to rise by 600 p.c | |
Healthcare; Insured workers feel the pain as high premiums end up on payslips Daily nation 27th July 2010 smart company pg 10: “Rising medical bill a bitter pill for employers | |
Advertising feature: Daily Nation 27th July 2010 pg 36: “The Evolution of NHIF” | |
Medical fees row; setback for national health insurer: Daily nation 11th Aug, 2010: Bid to block new NHIF rates certified ‘urgent |
Data analysis
Results
Historical account of NHIS in Kenya
“We realized that people are not accessing health, because of financial barriers. And health is putting about 1.5% of households below the poverty line. So we asked ourselves, ‘what is the best way forward?’ and in time to answer that question, we thought the best approach is for us to develop a financing strategy whose primary focus would be to tap the high out-of-pocket expenditure in an organized prepayment arrangement. That is how the debate of social health insurance came in and we prepared the sessional paper” (MoH actor).
Period | key activities/outputs |
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1965 | ✓ Sessional paper no 10 on “African Socialism and its application in Kenya” which outlined plans to provide welfare on a large scale. Government waived KES 5.00 charged to people |
1966 | ✓ Creation of the NHIF through an act of parliament to replace the existing racially discriminative scheme by providing a contributory hospital based cover for all Kenyans aged over 18 years in formal employment and earning over Kshs 1,000. |
1970 | ✓ Failure of local services to offer satisfactory services led to transfer of services to central government but no extra fund to meet the extra costs |
1972 | ✓ Voluntary NHIF membership was introduced to bring on board the informal sector and those earning less than Kshs 1,000. |
1986 | ✓ Sessional paper No. 1 of 1986 on “Economic Management for renewed growth”. Outlining Government priorities relating to financing of health care services including strengthening of NHIF and introduction of cost sharing in public health facilities. |
1989 | ✓ The cost sharing policy introduced in the public health sector (user fees) to mobilize additional resources in the health sector, reduce excessive use of resources and improve the functioning of the referral system |
1990 | ✓ Review of NHIF contribution premium rates having stagnated at Kshs 20 since inception of the fund to offset the impact of inflation and raising health care costs and also to generate additional resources towards financing of health care services |
✓ temporary suspension of user fees | |
1992 | ✓ Reintroduction of modest user fees |
1994 | ✓ Cabinet approved the Kenya Health Policy Framework a blue print for priorities in health care |
✓Review of the NHIF from being a Government department within the ministry of health into a state corporation, through Act of parliament | |
November 2001 | ✓ First national congress on quality improvement in health medical research and traditional medicine |
✓ President directed ministers to take action on measures to establish a mandatory NSHI for all Kenyans | |
✓ delegates adopted a resolution to include “right to health in the constitution” and adopted a task force report on affordable health care which recommended the establishment of NSHIF | |
January 2002 | ✓ Cabinet adopted a resolution for the establishment of NSHIF |
May 2002 | ✓ Minister of Health established an inter sectoral task force to prepare a national strategy and Draft bill expected to lead to the establishment of NSHIF with its members from government and private sector |
✓ A task force completed its work and submitted a strategy report and a bill to the minister | |
2003 | ✓ Economic Recovery Strategy (ERS) for Wealth and Employment Creation (2003–2007) strategy aimed at transformation the existing NHIF into a NSHIF |
June 2003 | ✓ MoH approached GTZ/WHO for technical support with 6th expert mission form June 2003-June 2004 to support implementation of the scheme once passed by law |
June 2003 | ✓ 1st Technical mission which reviewed strategy and draft bill which led to the draft sessional paper no 2 of 2004 |
August 2003 | ✓ 2nd mission which focused on the legal aspects of the NSHI bill-benefit package, provider systems, transition of NHIF-NSHIF |
October 2003 | ✓ 3rd Mission that focused on the health insurance management and financial feasibility of the implementation |
January 2004 | ✓ 4th mission which focused on the progress towards implementation change management process and implementation of the working group |
April 2004 | ✓ 5th Mission which reviewed progress to formulate mile stones |
June 2004 | ✓ 6th Mission on financial projections and trained Kenyans on financial simulations tool |
9th Dec 2004 | ✓ Debates in parliament and a bill was passed in but was not assented by the president on 31st Dec 2004 |
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The 1st mission conducted in June 2003 was responsible for reviewing the NHIS strategy paper, drafting the bill and the Sessional Paper number 2 on NHIS. Key recommendations raised by this mission was the need for a proper costing of the benefit package; having registration fees structured by levels of care to prevent overutilization; initial exclusion of long term illness; cost containment through quality management; mortuary charges limited to three days; and special review procedures for expensive drugs.
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The second technical mission set up in August 2003 focused on the legal aspects of the NHIS Bill, the benefit package and provider payments, the transition of the current NHIF into the NHIS and the implementation tasks. Key recommendations from this technical mission was the need to improve the NHIF image, which had a history of inefficiency and corruption, by promoting transparency and reducing the administrative costs to 10% for the first four years.
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The third Technical mission (October- November 2003) focused largely on the financial feasibility of the NHIS implementation. One key suggestion for this mission was inclusion of health facility based preventive services and curative care for both inpatient and outpatient services. HIV/AIDS and Tuberculosis were to be included but accounted for separately.
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The fourth mission set up in January 2004 concentrated on progress toward implementation of the NHIS, addressing the change management process and the activities of the NHIF working groups. It reviewed progress towards implementation of the NHIS, drafted the final version of the bill, and explored opportunities of integrating retirement schemes of armed forces later.
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The fifth Technical mission conducted between March and April 2004 aimed at reviewing the progress on the initial stage of NHIS implementation and to formulate milestones in the full implementation.
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The final Technical mission was organized in June 2004. It provided the revised financial projections through informal discussions with stakeholders and parliamentary committee on health. The main set back was the announcement of the introduction of free health care services for all Kenyans with effect from 1st July 2004. This reduced the willingness of the informal sector to contribute to the scheme.
“I think the year was to give us a break. Because when you push something too far, and you do not succeed, you do not want to start the whole thing too fast before your enemies have probably disbanded. We saw that we require one year, for us to rethink the whole process and probably use another platform to move the same agenda. And in this case we were just developing the vision 2030. And one of the pillars of vision 2030 is having a social health insurance framework. So we wanted to use the vision 2030, because remember the initial entry was the economic recovery strategy, we failed” (MoH actor).
Stakeholder’s perceptions of the NHIS design
Contribution methods
Pooling of revenue
“Multiple pools break the solidarity especially in a small system. For a small country, you need a strong solidarity element and once you categorize people, you will have to have a lot of cross subsidies across different groups” (Donor actor).
Purchasing
“we would want all Kenyans to pull resources into one pot and use it to finance the health care, for both the rich and the poor” (MoH Actor).
“There were some people who could not understand the request from the private sector, so they ended up signing an agreement to allow competition for NHIF only to realize the implications later” (Treasury actor).
“NHIF cannot be the same person who is collecting the money and at the same time utilizing that money” (NGO Actor).
“:…because you realize then you would have about 300 purchasers …. And if they are all doing whatever they want to do, it will be total chaos; some will be efficient while others will not” MoH Actor.
Provider payment mechanisms
Accreditation of health care providers
Benefit package
“....When they talk about management of HIV, there are so many ways of managing HIV/AIDS. So when they say renal management, there are so many elements of renal management, there is the dialysis and all that. And one episode of dialysis can cost you a substantial amount of money. But then they say they can afford that there is still some doubt. And then we have been asking for some evidence on the actuarial studies that has informed that benefit package” (private sector actor).
“And I think the argument then was that, let’s cluster this thing into three blocks. One is the primary healthcare. Things which are social… you know public goods in nature, and things where the private sector will not be interested to come in. and you say those things will be purchased and paid for by the government; immunization, condoms, you do not want the private sector to come in just because in the event that they don’t provide the goods, then the repercussions will be more than if the government provided them. Then we look at the secondary level” (MoH –actor).
Factors influencing the realization of the bill
Cost of implementation
“…because they looked at the cost of the entire project and said it was very expensive, but what they failed to flag out, is the process of implementing it in stages… which was part of the design…. so what treasury did is to flag out the final cost of the project, which was coming to around forty billion Kenya shillings, and said this is too expensive” (MoH actor).
“it was almost impossible to know the financial implications upfront” (Development partner).
Inadequate communication strategies
“The only issue is that I blame the political system that was supposed to connect; the technical people and the public. This failed us. They didn’t pass the correct message to the public. You can’t go to Kenyans and tell them we are going to consume … free healthcare services. There is always a price for everything. So that is one area we failed” (MoH actor).
“…..I would say there was some element of mischief…(MoH actor).
“I can tell you there were people silently… expressing some discontent about the draft proposal...... If you are to compare it to some strategies that we have from other countries, you will realize that ours does not bring out the issues clearly, like the role of the different organs like NHIF, the role of the private sector and all that” (MoH Actor).
Fear of implications of the changes
“We have since come through a very big transformation….what will it mean to our businesses? So it was a genuine concern” (private sector actor).
“They did not understand how this is going to work out. We were not seeing each other as players and all of us have space. … if this system works out then it means I will lose my…cut!……I will reduce the profits that I get!” (NGO actor).
Trust, transparency and governance
“other non-government players are very strong. So if you don’t have their backing whether your idea was good or not it’s likely to fail purely because you did not involve, it was not participatory, you see?” (Private sector actor).
“And at that time the NHIF was very inefficient, spending too much money on administration, and we thought in that Bill we should cut the level of administration costs, and we put it at 10%. And we also wanted to look into contribution at a rate of 2.5% per person. So that was not very contentious but the most contentious issue was this animal we are giving money, how efficient is the animal that is now NHIF” (Private sector actor).
“And during the preparation, we mobilized all the stakeholders; Central Organization of Trade Union (COTU), Federation of Kenya Employers (FKE), private sector, teachers union… to rally them behind …… what we thought was a noble objective” (MoH actor).
International influence
“….you find people concentrating on certain things that are not the priority of the country.. but these guys don’t want to hear about health care financing broadly they are pouring a lot of money may be to HIV” ( Treasury-actor).
“Those vertical programs have an impact but I don’t think it’s a real impact … I have a feeling that it’s very program oriented, we want to do this, once we are done, that’s it (Health insurance actor).
“There were two issues from the donors. One of the issues was that ‘if this thing happens, what will be our role in the health sector? That if the MoH is able to mobilize ninety billion, and their money (donor funding) then was about a billion, you know, they have no role in the health sector. So that was a major fear, and in fact they used that fear to cause some key donors to agitate the private sector to campaign against the social health (private sector actor).