The benefits of NHIF's controversial caps on outpatient cover

The National Health Insurance Fund (NHIF) recently got into trouble when it attempted to cap the number of outpatient visits for its 26 million members to four per year, sparking a strong backlash from Kenyans, especially on social media.

However, in the public debate about the proposal made public by NHIF CEO Geoffrey Mwangi, it appears that some vital issues have remained obscured or downplayed to some extent.

The capping of outpatient visits would have allowed the insurer to dedicate more of the funds it collects from members to inpatient services and chronic conditions whose treatment costs usually strain many families. These include kidney diseases, cancer, diabetes, high blood pressure as well as surgery.

Currently, NHIF prepays significant amounts of funds to health providers for outpatient services for the treatment of common diseases whose treatment costs are less likely to leave the majority of families in financial strain. This may include cough, diarrhoea and malaria.

Treating these diseases may be burdensome to low-income families but in most cases they are unlikely to cause them to sell property or seek loans for treatment as is the case with chronic conditions and surgeries whose costs range in the hundreds of thousands or millions of shillings.

Chronic diseases

There is no doubt that since it was introduced, NHIF's covers for inpatient services, chronic diseases and surgery have helped many families get healthcare they would never have afforded by themselves, thus saving lives.

The Ministry of Health projects that the incidence of chronic and non-communicable diseases is rising rapidly in Kenya as poor diets and sedentary lifestyles take their toll. The burden on the health sector is rising and appropriate financing as well preventive measures will be critical.

Maybe NHIF should have introduced an improved package for inpatient and chronic diseases concurrently with the announcement of the cap on the outpatient visits, to make the latter an easier sell to Kenyans who are covered by the insurer.

The cover for in-patient and chronic diseases was raised significantly early last year and further improvements should be considered to cushion members from catastrophic and unexpected illnesses requiring costly care. In its current form, the cover is not such a bad deal for annual contributions of between Sh6,000 and Sh20,400, but there is room for improvement.

It is worth appreciating that NHIF, like any insurer, does not have a bottomless pool of resources to finance healthcare but relies on funds remitted by members in both the formal and informal sectors.

Therefore, without prioritising the best use of members' funds, the insurer cannot sustainably operate. The fund  receives no budgetary allocation from Treasury.

Recent studies

Some relatively recent studies have indicated on average, Kenyans without chronic lifestyle conditions or in need of surgery visit health providers two to four times a year for outpatient services. This may have informed the NHIF decision to cap outpatient visits for members to four per year, leaving families to foot the costs of extra visits.

But to make it more palatable to Kenyans, NHIF could consider increasing the number of outpatient visits for members from the four per year initially proposed without straining its financially capacity to breaking point.

An appropriate number could emerge from wide-ranging consultations with stakeholders that Health Cabinet Secretary Cleopa Mailu proposed when he suspended the "four-visit-per-year" outpatient arrangement. On their part, NHIF should also do more to consolidate and grow the pool of resources it receives from contributors to deliver more benefits to members.

More robust measures are needed to recruit more members, cut administrative costs that are eating into contributors' funds and tackle increasing cases of fraud by health facilities, with the suspected complicity of some NHIF staff. Wastage, inefficiencies and graft in procurement systems should be tackled urgently.

The fund must deliver sustainable health insurance sooner rather than later to unlock the socio-economic potential of Kenyans.

Mr Jamah is a media practitioner [email protected]