A raft of measures to turn around the fortunes of Kenya’s largest health insurance fund have given a ray of hope to hundreds of thousands of needy patients, but a biting lack of awareness is preventing thousands more from enjoying the low-hanging fruits.

From a struggling operation barely 10 years ago, the National Health Insurance Fund (NHIF) is now offering enhanced financial services, including treatment locally and abroad, an improved maternity cover, as well as full coverage of kidney dialysis and heart surgery costs.

For an organisation with a fairly dark past, and above which a dark, ominous cloud still hangs, the turnaround has not gone unnoticed to a lot of Kenyans.

Among these is Samuel Wanjala Wanyama, a 40-year-old boda boda rider in Nairobi who recently lost his wife to breast cancer. The love of his life, Judith Iminza, died last month after spending nearly 110 days in hospital. She left an outstanding bill of Sh638,544.

Although Wanyama has to find a way through his tough boda boda business to get the money to pay the bill at Kenyatta National Hospital, there is a silver lining in the dark cloud; he only has to pay Sh140,075 as the national insurer has promised to foot the remaining Sh498,469.

Initially, when Wanyama’s wife fell ill, he sought treatment twice at a mission hospital but was turned away because the facility does not accept NHIF cards as a mode of payment.

“We spent nearly Sh40,000 on the two instances when she was admitted,” he says. “I fundraised from family and friends.”

Later, his wife was referred to Kenyatta National Hospital. “It was a relief when the hospital told me that NHIF would step in, otherwise I would have had nearly half a million shillings to pay,” the father of two told HealthyNation.

Mr Wanyama has been contributing Sh500 every month to NHIF since January and he hopes to keep at it, especially now that he has included his two children as dependents on his NHIF cover.

Last year the Fund introduced enhanced benefits that saw patients with chronic diseases get better deals, where they would seek treatment for diseases like cancer at almost no extra cost. With the new benefits, the Fund pays for chemotherapy and radiotherapy sessions for many needy patients.

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Many patients still do not know that they must first seek pre-authorisation from the NHIF headquarters, which involves having a form filled in by the attending doctors specifying whether they require chemotherapy or radiotherapy, the sessions needed, and any other drugs required, before they can be treated. PHOTO | FILE

ACCREDITED FACILITIES

But it is not as straightforward, as would be expected. Many patients still do not know that they must first seek pre-authorisation from the NHIF headquarters, which involves having a form filled in by the attending doctors specifying whether they require chemotherapy or radiotherapy, the sessions needed, and any other drugs required, before they can be treated.

Apart from cancer, the enhanced packages also cover treatment for renal ailments, which is what Wahid Farjalla, 49, relies on for lifesaving dialysis in public hospitals in Mombasa County.

The father of four suffers from polycystic kidney disease and has lived with the ailment for 12 years.

“I rely on NHIF for everything, right from medicines to treatment because the card works for me. I have never had to pay any extra money whenever I seek services at a public hospital,” he says.

Apart from dialysis, doctors at Coast Provincial General Hospital inject Mr Farjalla with drugs to boost his red blood cell count twice a week at no extra cost, since NHIF pays for that too. For the same treatment at a private hospital, he would have to pay Sh5,000 in cash, which he did when doctors went on strike for three months at the start of the year.

Not all patients, however, think NHIF has served them well. David Mayiani, for instance, laments that he had to dig into his pocket to pay for dialysis at Parklands Kidney Centre in Nairobi because the bureaucracy at the Fund was too much for him to bear.

But the Fund’s chief executive officer, Mr Geoffrey Mwangi, who took the helm this year, says those checks and balances are important in the wake of the enhanced covers, which come at a huge cost.

“Kenyans can receive chemotherapy, radiotherapy and dialysis in accredited facilities,” says Mr Mwangi. “We have also improved our maternity package for both normal deliveries and Caesarean sections.”

The Fund currently uses up to 85 per cent of its annual collection of about Sh33 billion to pay for diagnosis and treatment of patients who have signed up for the cover, and Mr Mwangi says there is a low uptake of the outpatient package on the national scheme. Premium contributions are calculated on a graduated scale based on income, and deducted automatically through payroll.

For self-employed and other informal sector workers, membership is contributory (voluntary) and available at a fixed premium rate of Sh160 per month.

Although contributions to the Fund are a statutory deduction that has to be remitted on a monthly basis, Mr Mwangi explains that the informal sector is rarely consistent.

“We have put in place a three-month restriction on usage of the card for self-employed contributors to avoid having people who only enroll when they are seeking services,” he says.

BIGGER ILLNESSES

While admitting that NHIF could do better, Mr Mwangi says that the parastatal has had to deal with a number of challenges relating to fraud.

“Medical fraud is real. While there are some types that we can tame, some are difficult to address — like curbing impersonation because it is almost impossible to verify whether the documents presented by the patient really belong to the patient.”

Last year, NHIF announced that under its new Chronic Disease Fund it will pay up to Sh5 million for civil servant and disciplined forces members seeking treatment outside the country. Other members referred to hospitals overseas for specialised treatment are allowed up to Sh500,000 in treatment costs, depending on the severity of the illness. This benefit, however, is limited to  patients with diseases that cannot be treated locally.

The fund prioritises chronic diseases such a cancer, kidney failure and liver transplants, among others.

In addition, the National Aids Control Council has been in talks with NHIF to see if HIV treatment may be covered. Towards that end, a feasibility study is going on.

There are nearly 1.6 million Kenyans living with the virus, about a million  of whom are on treatment, and the country records at least 100,000 new HIV infections annually.

People who test positive for HIV are put under ARV treatment immediately under the Anza Sasa programme. The government spends about Sh20,000 a year to put a single HIV patient on ARVs.

Health insurance is vital in HIV management as Kenya will require about Sh1.75 trillion by 2030 to prevent at least 1.5 million new HIV infections, according to the National HIV and Aids Estimates report.

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NHIF headquarters in Nairobi. The health insurer remains the focus of allegations of scandals. PHOTO | FILE

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The dark cloud

Away from the rosy stories, the national insurer remains the focus of allegations of scandals. This, however, is not new to the Fund. As early as June 7, 1995, Prof Anyang’ Nyongó criticised NHIF, alongside National Social Security Fund (NSSF), for collecting “too much money” but doing “too little”.

Twenty-two years and several scandals later, the same accusations still besmirch the scheme. The 2016 economic survey reported that, in 2015, 5.3 million Kenyans were members of NHIF, and three in five of those members were in formal employment, and so were most likely to have private health insurance from their employers, in addition to the mandatory NHIF.

According to the 2013 Kenya Household Health Expenditure and Utilisation Survey, only about two in every five Kenyans (17.1 per cent) had some form of health insurance cover.

“The National Hospital Insurance Fund (NHIF) covered 88.4 per cent of those insured, while private insurance covered 9.4 percent,” states the report. 

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NEW NHIF BENEFITS PACKAGE

1. Registration and Consultation

This covers costs related to registration and consultations in hospitals. 

2. Medicines and medical supplies

Covers for the costs as per the National Essential Medicines List (NEMLIT) and additional medicine list recommended (to NHIF) by experts 

3. Investigations

The Fund covers for the costs of investigations and diagnostic tests as per the investigation list in the benefits package. There are 321 medical investigations, including ultrasound, echocardiography, CT-Scan and MRI 

4. Surgical Services

Includes minor, major and specialised surgical services in health centres all the way to referral hospitals 

5. Inpatient Care Services, including ICU and HDU

Covers for the daily admission costs depending on the level of the facility, investigations, medicines and medical consumables dispensed while the member is admitted 

6. Physiotherapy and rehabilitation services

This is provided to inpatients and outpatients where the facility has specialists for the same 

7. Eye and Optical Services

NHIF covers the costs for optical services to all beneficiaries (Treatment of eye diseases and refraction for visual defects) 

8 Spectacles

 The Fund pays for visual corrective spectacles to the principal member (one pair for a period of 3 years). 

9 Dental and Oral health Services

 This is provided to inpatients and outpatients where the facility has specialists for the same. This includes dental conservation surgeries (carries and dental filling), gum diseases, dental extractions and root canals 

10 Retirees Health Benefits

Comprehensive medical services are offered to the retired principal members and their spouses, for their entire lives 

11 Medical/Orthopaedic Appliances

The Fund provides supportive orthopaedic and medical appliances, including white cane for blind people, neck and thoracic spine collars, hearing aids, lumbar cossets and braces, walking crutches and leg orthopaedic supports — ankle, knee and above-knee supports