New Health Insurance Scheme; The Devil Is In The Guidelines

By Peter Ngure

The Kenyan constitution 2010 provides under 43 (1, a) that Every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care; Article 43 (2) also recognizes that A person shall not be denied emergency medical treatment. It recognizing the role of the Government as a duty holder and is responsible to ensure health services do not expose the citizens to financial hardships

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Indeed, one of the most critical challenges faced by Kenyan Health systems is the generation of a sustainable financing mechanisms capable of delivering universal health coverage for her people as most informal sector workers representing 83.3% of the total Kenyan workforce and have no health insurance, exposing entire families to impoverishment and risk of reversing progress made in achieving health outcomes in the country.

Kenya despite the hurdles is committed to achieving universal health coverage with the current government making strides to its realization by passing four of the Universal Health coverage laws including the Social Health Insurance Fund (SHIF), Facility Improvement Financing, Digital Health and Primary Health Care.

This proposed shift comes at a time when reliance on donor funding has declined given the county elevation to a low-middle income country and poses a risk on progress made in achieving the SDG Goal 3 focusing on reducing maternal, newborn and child mortality and in achieving the Kenya 2016 RMNCAH investment framework which focuses on strategies to address these major bottlenecks and gaps.

The recent reforms and regulatory frameworks set forth in the Social Health Insurance (General) Regulations, 2023 are designed to enhance healthcare accessibility, affordability, and quality.

An analysis by Pathways Policy Institute suggests that the 2.75% deductions from employed Kenyans through the SHIF could potentially double the total contributions from Kshs. 60 billion collected by National Health Insurance Fund (NHIF) annually to Kshs. 125 billion, such an increment brings significant implications for Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH) in Kenya as the legislation also aims to enhance their access and quality to health.

Focusing on the specific needs of vulnerable groups such as women, children, and adolescents. Importantly, specific services such as antiretrovirals (ARVs), HIV testing, family planning, anti-malaria, and vaccinations are provided at no cost to the patient, enhancing accessibility and affordability.

Under the Primary Healthcare Fund, outpatient care services that are accessible at Level 2, 3, and 4 primary health care referral facilities have a tariff set at KES 900 per person per annum with the and can only be accessed by a family in the Primary Care Network in which they are mapped under.

Facilities are mapped to a Primary Care Network (PCN) with a global budget allocated based on population and patient visits. The Primary Healthcare fund however will only be disbursed at the end of each quarter meaning the facilities have to foot their initial bills; if a facility isn’t able to do so, this will lead to citizens chipping in using the Out of Pocket.

RMNCAH services within the primary healthcare framework include comprehensive reproductive, maternal, and child health services as defined by the Ministry of Health (MOH) guidelines. This includes immunizations, minor surgical procedures, and the management of endemic diseases, thereby ensuring holistic care from preconception through adolescence.

Maternity services are particularly robust, covering antenatal care, various forms of delivery (normal, assisted, and caesarean), aftercare for both mother and newborn, midwifery services, immunizations, and the management of complications.

These services are available at Level 2-3 facilities with tariffs set at KES 11,200 for normal delivery and KES 32,600 for a caesarean section, covering hospital stays of up to 48 hours for normal deliveries and 72 hours for caesarean sections.

The challenge with this provision is on a disclaimer that incase of peripartum and postnatal complications, then per diem rates takes effects and claims will have to undergo surveillance before being granted. It also indicates that management of complications for the new born will be charged separately from the mother at a daily rebate rates for inpatient services meaning that post the 48/72 hours, the costs start being incurred by the patient, be it as a per diem rate.

Financial protection and accessibility are also key features of the Act. It aims to reduce the financial burden on families seeking RMNCAH services by providing a structured financing mechanism through the Social Health Insurance Fund and the Primary Healthcare Fund. This ensures that essential healthcare services are accessible to all, regardless of financial status.

The Act includes provisions for financial assistance to households in need, ensuring that the poorest and most vulnerable populations can access RMNCAH services without financial hardship. By covering a wide range of services, the Act significantly reduces out-of-pocket expenditure for families, making healthcare more affordable and accessible.

Impact on Maternal, reproductive and Child Health Outcomes

While the Act and guidelines comprehensive coverage and quality assurance measures are expected to significantly improve maternal and child health outcomes, the costs and guidelines are leading citizens to worry about full access and choice.

For instance, under imaging, a household can only access Mammography services 2 times per household per year. MRI including specific obstetric conditions can only be done at the rate of two images per household per year.

The Two images and scans per family limits the enjoyment of the right to healthcare for paid up members, especially when a household has more than 2 females.  Other challenges include the access rules of outpatient services where outpatient visits are limited to 4 per person thus seemingly dictating that one can only fall ill 4 times a year!