What to expect as NHIF paves way for SHA

As the National Hospital Insurance Fund hurtles towards its sunset in a matter of weeks, it is heralding a new dawn. The Social Health Authority.

And the clock is ticking.

However, Winnie Miseda Atieno is hesitant to enrol in the new scheme, despite it being mandatory for all Kenyans.

The human resource and communication profession cites a lack of trust and transparency in the planned shift to SHIF (Social Health Insurance Fund, which falls under SHA.

“Unless I am convinced otherwise, I cannot enrol in the Social Health scheme. I am okay with private schemes because there is value for money,” says Atieno, a resident of Thindigua, Kiambu County.

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Atieno has been a member of the National Health insurance Fund (NHIF) since 2012, under comprehensive premium paying Sh1,700 monthly.

In 2022, she was diagnosed with hyperthyroidism disease that required an operation at a cost of Kshs 300,000.

NHIF covered the entire bill that entailed hospital admission, operation and doctors fee.

But last year, Atieno was forced to dig deeper into her pockets to raise Kshs 750,000 for a laparoscopic procedure after she was diagnosed with chronic helicobacter (H. pylori) infection.

Before surgery, she underwent CT Scan and endoscopy tests that were paid out of pocket, as NHIF did not cover them.

Shockingly, the fund only catered for Kshs 5,400, cost for bed, leaving Atieno to plead for support from her friends and well-wishers.

This was despite her having been a religious contributor to the scheme.

“Imagine being in deep pain, in need of service, but your request is rejected, with no feedback, only to have an approval of bed. I was devastated, the experience was not worth my contribution,” recalls Atieno.

She adds, “I felt insulted. Being a religious contributor of Sh1,700 monthly, only for NHIF to cover for bed alone, no drugs, no nothing. I felt disappointed”.

While she struggled for care, civil servants were accessing the service with the same cover.

“I got pissed off, you cannot tell me civil servants enjoy the benefits and some of us in private sector paying, in a lot of money, do not enjoy it.

I cannot be a contributor to a scheme then at the time of need, you are told you cannot get the service. It is not logical,” she observes, giving an example of her mother who still enjoys NHIF services in her retirement.

As the Ministry of Health gears up to transition from NHIF to Social Health Authority (SHA), effective on October 1, 2024, Atieno, like hundreds of Kenyans, is sardonic over it, hence hesitant to register to the scheme.

“Unless policies and procedures change, I am not registering to the scheme because I do not expect anything good with the new scheme. It beats logic to enroll to a scheme, yet you go to hospital, and you are turned back, and be given drugs that are less than Kshs 150, yet those required cost more than Sh2,000,” questions Atieno.

Healthcare in the country, she adds, is expensive, an issue that can be handled if corruption in the public health sector is weeded out.

“A number of people are managing health with painkillers because of fear of being diagnosed, more so with chronic disease that are expensive to treat. What is killing Kenyans is not illnesses, but the inability to have money to go access medication and healthcare and walk through it,” observes Atieno.

Despite the misanthropism from Kenyans in registering to the scheme, Medical Services Health Principal Secretary, Harry Kimtai, maintains that “registration to the new scheme by all Kenyans is a must”.

In an in-depth interview with The Standard, Kimtai insists that SHA will serve all Kenyans, unlike NHIF, which he says was discriminatory and mostly targeted the employed.

Presidential advisor on health who is also a  health economist, Dr Daniel Mwai, says healthcare financing has been a major challenge in the country, an area that has been corrected under SHA, a system thae he adds, is a creation and improvement informed by past systemic failures.

Current reforms worked in the new scheme, he highlights, are backdated to 2003.

“Insurance has people with diseases subsidised by those who do not have, the rich subsidise the poor, and young subsidise the old, and therefore come up with a healthcare system that is stable,” explains Mwai, also a lecturer at the University of Nairobi.

The new scheme entails pooling risks and having an established premium.

“It is a very noble course, whether done by this government or not. The idea that we should all reconcile to is that everyone gets sick, and sickness is not a choice. We have had 21 years of discussion on the change of health reforms," says the health economist.

He adds, “In principle, we are in the right direction. The gratitude and strength of doing it is where we are going to have a challenge. I am optimistic that we shall be able to manage.” 

NHIF, according to Mwai, heavily targeted 20 per cent of Kenyans in formal employment, leaving out 80 per cent in the informal sector, who are all included in the new scheme.

In the new scheme, deductions have been capped at 2.75 per cent, with low-income earners paying less compared to NHIF.

For instance, an individual earning Kshs 3,000 shall pay Kshs 82.50 as compared to current monthly deductions of Kshs 150 to NHIF.

"If people say they want to go back to NHIF, they simply say oppression of the poor. For example, if someone is earning Kshs 6,000 your pay collected is about 5 per cent, the number reduces as income increases,” observes Mwai.

He adds, “This is a system that punishes the poor for being poor. Reforms are bringing equity".

He points out that the fund also did not provide adequate insurance to patients with chronic diseases in need of services like chemotherapy and dialysis.

“As a way of responding to the current health needs, the ministry came up with Social Health Insurance Act, that brings on board three funds, namely the Primary Healthcare Fund, Social Health Insurance Fund (SHIF), and the Emergency, Chronic and Critical Illness Fund (ECCIF),” PS Kimtai explains.

In SHA, the exchequer will cater for Primary Healthcare Fund and Emergency, Chronic and Critical Illness Fund, whereas contributions shall be made to SHIF.

Patients who deplete SHIF will access care with the Emergency and Chronic Illness Fund (ECCIF).

The new scheme also does not have premiums, with standardised services devoid of the amount contributed to the scheme.

“SHA has to be uniform for all Kenyans. It is for all Kenyans, we are pulling resources together as Kenyans. Every Kenyan, rich or poor, will be entitled to the service,” says Kimtai.

Civil servants have, however, criticised the scheme since they want to continue enjoying the scheme.

“As civil servants, we have enhanced cover; with the enactment of SHA, it doesn't feature where the government will be able to provide such a cover, yet in labour, it doesn't allow taking employees from a superior cover to inferior cover,” says Kenya Union of Clinical Officers (KUCO) Secretary General George Gibore.

In a quick rejoinder, Kimtai defends the scheme, saying civil servants are at liberty to get a different health provider.

“All of us shall pay equal amount; it makes us equal. Having civil servants scheme is what was bringing disparity. There was no uniformity,” maintains PS Kimtai.

Benefit package components in the new scheme include medical outpatient services, medical inpatient and critical care services, renal services, assistive devices, end-of life services, together with accident and emergency services.

The authority is also expected to further oversee treatment, maternity and child health services, oncology services, medical imaging, screening of common disease and rehabilitative services.

Pricing of health services across all hospitals in the country will also be standardised under the new medical scheme, with tariffs for charges offered in private, public and faith-based hospitals shall be uniform in SHA.

For instance, hospital deliveries are capped at Sh11,200 for normal deliveries and Sh32,000 for Caesarian Section (C-Section), charges that cut across all hospitals.

Dialysis has been allocated Sh10,650 per session, and peritoneal dialysis has been allocated Sh180,00 per month.

In the scheme, mental services include rehabilitation for substance related addictive disorders, screening, management, and referral of behavioural, affective, and psychoactive disorders, and mental health education.

Inpatient service for mental illnesses will be allocated Sh1,200 per visit, in addition to Sh12500 for rehabilitation.

With increased cases of cancer, the cover will remit Sh5,000 for administering chemotherapy, Sh53,500 for PET Scan, Sh40,000 for brachytherapy, and up to Sh3,600 per session for radiotherapy.

Mortuary fee of Sh500 has also been included in the new scheme, a service that was not under NHIF.

Other services include dental healthcare, optical services, surgical and specialised pharmacy benefits, which were excluded in NHIF.

Despite much weight put on funding of healthcare and reforms, Gibore maintains that human resource is key and should be addressed for Universal Health Coverage to be realized.

Further, the clinical officer's representative urges the government to set up proper structures and policies to handle fraud.

According to Mwai, the majority of fraud cases witnessed in NHIF are abated because of leakages in the system. The system also suffers from human interface within, which aggravates leakages.

As a mitigation, the new scheme comes with digitalised resources.

“Automation will help track and have a track of who did what, when and where. This will cut down the requirements of human beings. Automation also increases efficiency, as machines do better than human being, and if human being are required, they will be in place,” says Mwai.

Kimtai adds that to avoid payment of excesses in terms of capitation to private hospitals as witnessed in the past, Kenya Medical Practitioners and Dentist Council (KMPDC) has been mandated to register all hospitals on behalf of SHA.

KMPDC and The Nurses Council have further been asked to submit names of all registered doctors and nurses for documentation into the human resource registry.

In the event of fraudulent claims, KMPDC will deregister the hospitals, and take action against individuals involved.

All hospitals will also be linked to a central point through the National Digital superhighway, while patients will be identified through a patient's registry.

“Fraudulent claims will lead to the loss of your licence automatically. It was difficult to trace some of these hospitals and individuals indulging in fraudulent claims because the records were manual, but now all records are digitalised,” cites Mr Kimtai.

In the claims list under the new scheme, it will not be possible for a doctor to make two claims. In the scheme, a doctor cannot claim for payment at a private hospital at a time they are expected to be serving patients in a public facility.

Kimtai pleads with Kenyans to register for the new scheme to cut their financial burden.

Registration to the new scheme is biometric, where Kenyans shall present their Identification Card (ID), alongside verification of fingerprints, unlike manual registration witnessed during the reign of NHIF.