Families suffer as millions lie idle at NHIF

NAIROBI: Life for Lameck Tala and his family has never been the same since finding out that their 10-month-old son needed a liver transplant. That was three months ago. The father was identified as the donor, but the cost of the procedure was way beyond their means—Sh5 million.

Tala, his wife and their son would have to stay in India for between two to three months after the surgery for monitoring and to allow father and son recuperate. Weeks after the diagnosis, family and friends had raised less than Sh2 million and the clock, as the doctors warned, was ticking fast for the baby. It was then that a friend suggested they approach the National Hospital Insurance Fund (NHIF) for help in meeting the costs.

“My wife and I are contributors to NHIF, but I had no idea they could pay for medical costs if one sought treatment outside the country. I approached them and they were willing to help. I have been running around to get the paper work done because NHIF needs to get a justification to pay for the treatment. This has meant getting letters from the doctors handling my baby’s case to prove the procedure is not available locally. I have also had to seek clearance from the Ministry of Health,” says Tala.

The family has already travelled for treatment.

Elsewhere Catherine Meme is surprised to hear that NHIF can pay for a member’s treatment abroad. Her husband, James Meme, a former Assistant Administration Police Commandant, was diagnosed with kidney failure in April 2014.

Five months later, he left for treatment in India where he was to undergo a kidney transplant, only for another diagnosis to be made. He had prostate cancer.

The discovery changed the initial plans for treatment because it meant he first had to be treated for prostrate cancer before undergoing the kidney transplant. Meme returned home in January 2015, having exhausted the Sh2.5 million collected from friends and family. He now requires another Sh1.2m to undergo the transplant.

“My husband contributes Sh500 per month to NHIF. He goes for dialysis twice a week at Kenyatta National Hospital and NHIF pays Sh2,500 per session. But I wish they (NHIF) could help us meet the cost of his transplant,” says Catherine.

Despite being unemployed, making monthly contributions of Sh500 to NHIF has always been a priority for 43-year-old Clay Khama.

The father of one, who previously worked in the private sector but quit owing to poor health, needs Sh 4.5m to enable him undergo a liver transplant in India. But he too, like many other contributors to the fund has no idea NHIF can chip in towards his medical expenses abroad.

LIMELIGHT

In fact, NHIF recently footed a Sh7 million bill for the University of Nairobi student Emmanuel Otieno (Jadudi) who shot to the limelight following a social media campaign to raise money to enable him undergo surgery for a brain tumour in India.

While the cases above illustrate different outcomes for contributors to the fund, many questions remain on NHIF’s criteria in meeting medical expenses of its members seeking treatment abroad, particularly among those with chronic conditions. For instance, what criteria does NHIF use to determine what cases to take up? Is NHIF obliged to chip into any of its member’s medical treatment abroad? If so are there limits to how much it can pay? What conditions must one meet? Are there restrictions with regards to the choice of country one may seek treatment?

Just two week ago, NHIF announced that under its new Chronic Disease Fund, members will from this year use their cards to get treatment abroad for up to Sh5 million. The benefit will be limited to diseases that cannot be treated locally, with cancer and kidney disease getting priority.

The announcement was no doubt good news to its members but it appears information in the public domain on what the fund provides remains scanty.

“We generally don’t discriminate against our members. Any member seeking treatment abroad will get reimbursements, but there are limits on the amounts. Otherwise we give every contributor an equal chance, “ says NHIF Senior Public Relations Officer Gerald Kainga.

He dismissed claims that the fund appears to ‘favour’ members of the disciplined forces and the civil service. “That is not true. These members fall under a negotiated scheme arrived at about three years ago that saw the Government ‘buy’’ them under a collective cover,” says Kainga.

Currently, civil servants and members of the disciplined forces have their entire bill, inclusive of air tickets, met by NHIF. This is, however, subject to pre-authorisation by the Director of Medical Services and NHIF. Other members seeking treatment abroad and seeking reimbursement from NHIF get a rate of Sh1,700 per admission day.

Members of the civil service and disciplined forces have a comprehensive medical scheme that includes outpatient and inpatient medical treatment, both locally and abroad, maternity, optical and dental covers a well as ex-gratia payments. They also have a Group Life and Last Expense cover that is only available for the Principal Member. The Principal Member is also entitled to an annual general medical check-up at selected hospitals. Treatment costs for members arising from a condition that requires treatment abroad is also covered, subject to pre-authorisation by NHIF.

NHIF’s premium rates for members earning Sh100,000 and above stands at Sh1,700, while those earning up to Sh5,999 pay Sh150 monthly. Self-employed members contribute Sh500 per month.

While it is compulsory for those in the formal sector to be members of the fund, membership for retirees and those in the informal sector is voluntary. So has NHIF been meeting medical costs of all its contributors seeking treatment outside the country?

“For NHIF to meet medical expenses of a member seeking treatment abroad, there must be ‘’justifiable cause’’, including whether the services they are seeking are available locally or not,” says Kainga.

STEPPED IN

While what constitutes ‘justifiable’ remains debatable, Kainga says NHIF has on several occasions stepped in to pay for its members seeking treatment abroad but “does not publicise’’ this. According to its records, 430 members have so far benefited from treatment abroad, under the civil servants scheme.

Statistics of other members who have had the Fund foot medical expenses for treatment sought abroad stand at about 257 cases in the year 2014/2015. This represents a rise from 186 cases in 2013/2014. While details on how much the fund has spent In reimbursing members that have sought treatment abroad, were not immediately available, NHIF estimates to have spent Sh163,795,302 in foreign claims on 177 patients under the Civil Service and Disciplined Services (CSDS) cover. This figure was as per early 2015. NHIF has several covers including the Health Insurance Subsidy Programme (HISP) for the vulnerable, older persons and those with disabilities.

Under the National Scheme, an Inpatient cover gives members access to hospital accommodation charges, nursing care, diagnostic or laboratory services, physicians, surgeons, anaesthetists or physiotherapist’s fees.

Operating theatre charges, specialists consultations or visits, drugs dressings as well as ambulance services for transportation and transfer of a sick member or dependant are also included. Services one can access under the outpatient cover include consultation, laboratory and X-ray services, dental, optical care, minor surgeries, occupational services and referrals for specialised services.

The maternity cover caters for consultation and treatment for both mother and child, normal and ceasarian section, as well as family planning services, excluding fertility treatment.

But there is still a feeling that NHIF’s increased monthly premiums are not commensurate to the services offered. According to Kainga, the fund will review compensation rates for hospitals to ensure continued quality health care services.