Kenya
In 1966 the MOH established the National Hospital Insurance Fund (NHIF) as a department, with the social principle that “the rich should support the poor, the healthy should support the sick, and the young should support the old.” Since its independence in 1963 Kenya has historically had a centralized approach to health care, with the Ministry of Health (MOH) overseeing and organizing the health field. In 1966 the MOH established the National Hospital Insurance Fund (NHIF) as a department, with the social principle that “the rich should support the poor, the healthy should support the sick, and the young should support the old.” NHIF provided insurance for salaried employees earning at least KES 1,000 per month. Members contributed KES 20 monthly in order to receive comprehensive in-patient benefits at affiliated hospitals. In 1972, voluntary members were allowed to participate in the Insurance Fund, contributing a monthly KES 60 for in-patient coverage. In 1990 graduated scale for contributions based on wages was introduced, with a cap at KES 15,000 per month with monthly contributions ranging from KES 30 to KES 320.
In 1966 the MOH established the National Hospital Insurance Fund (NHIF) as a department, with the social principle that “the rich should support the poor, the healthy should support the sick, and the young should support the old.” Since its independence in 1963 Kenya has historically had a centralized approach to health care, with the Ministry of Health (MOH) overseeing and organizing the health field. In 1966 the MOH established the National Hospital Insurance Fund (NHIF) as a department, with the social principle that “the rich should support the poor, the healthy should support the sick, and the young should support the old.” NHIF provided insurance for salaried employees earning at least KES 1,000 per month. Members contributed KES 20 monthly in order to receive comprehensive in-patient benefits at affiliated hospitals. In 1972, voluntary members were allowed to participate in the Insurance Fund, contributing a monthly KES 60 for in-patient coverage. In 1990 graduated scale for contributions based on wages was introduced, with a cap at KES 15,000 per month with monthly contributions ranging from KES 30 to KES 320.
Due, in part, to the increased number of people with health insurance and the central government’s focus on health, by the 1980s Kenya had quadrupled the number of health facilities, extended its life expectancy from 40 to 62 years, and improved child mortality rates. Despite the improvements in health outcomes, the economic downturn of the 1980s combined with rising rates of HIV/AIDS infection exacerbated the number of health challenges for Kenya and created persistent financial difficulties. To combat the challenges, Kenya instituted user fees, which reduced attendance at government health facilities by 40-50%, especially for the poor. In response to this, District Health Organizations waived fees for the poor and children under the age of 5. Unfortunately, difficulty in identifying the poor and lack of systematic methods to reach informal workers blocked outreach to these groups and inclusion in the program for the vulnerable.
In 1993 the MOH began working on a health reform plan employing decentralization as a guiding strategy. In 1994 the Kenya Health Policy Framework Paper (KHPFP) was published, aiming for “quality health care that is acceptable, affordable, and accessible to all” by 2010. The KHPFP was implemented through 2 five-year National Health Sector Strategic Plans (NHSSP), which worked to decentralize the health system by assigning more management activities to district level organizations and organizing a Sector Wide Approach (SWap) that brings together all stakeholders (the government, donors, NGOs) under a single budget, monitoring system, and coordinating function. The NHSSP also implemented the Kenya Essential Package for Health (KEPH), which shifted the health focus from vertical disease-specific to an emphasis on 6 stages of the human life cycle (cohorts).
NHIF exists alongside the private health insurance sector. While only about 2% of the population is covered by the private insurance market, the sector is still one of the most developed and dynamic in Sub-Saharan Africa.. Private insurers generally focus more on middle and high income groups, providing health insurance at premiums that are related to risk.
In an attempt to create a health insurance network with wider and more equitable coverage, in 2004 the National Social Health Insurance Fund (NSHIF) was proposed to achieve universal health coverage by imposing a social tax on the employed to subsidize health insurance for those who cannot pay. NSHIF was passed by Parliament in 2004, but due to a number of protests and questions about the structure, financing model and from both the private sector and the civil society the President returned it for debate and it was subsequently not passed. As a response, a 10/20 policy was implemented to lower outpatient expenses, involving a payment system through which primary health care provided at dispensaries and health centers is free for all citizens, except for a minimum registration fee of Kenya Shillings (KES) 10 at dispensaries and 20 at health centers (approximately USD 0.2 and 0.3). Unfortunately, payments are still required for the majority of services, even vulnerable groups, essentially negating the social justice aspect.
Kenya
Historical Context
In 1966 the MOH established the National Hospital Insurance Fund (NHIF) as a department, with the social principle that “the rich should support the poor, the healthy should support the sick, and the young should support the old.” Since its independence in 1963 Kenya has historically had a centralized approach to health care, with the Ministry of Health (MOH) overseeing and organizing the health field. In 1966 the MOH established the National Hospital Insurance Fund (NHIF) as a department, with the social principle that “the rich should support the poor, the healthy should support the sick, and the young should support the old.” NHIF provided insurance for salaried employees earning at least KES 1,000 per month. Members contributed KES 20 monthly in order to receive comprehensive in-patient benefits at affiliated hospitals. In 1972, voluntary members were allowed to participate in the Insurance Fund, contributing a monthly KES 60 for in-patient coverage. In 1990 graduated scale for contributions based on wages was introduced, with a cap at KES 15,000 per month with monthly contributions ranging from KES 30 to KES 320.
Due, in part, to the increased number of people with health insurance and the central government’s focus on health, by the 1980s Kenya had quadrupled the number of health facilities, extended its life expectancy from 40 to 62 years, and improved child mortality rates. Despite the improvements in health outcomes, the economic downturn of the 1980s combined with rising rates of HIV/AIDS infection exacerbated the number of health challenges for Kenya and created persistent financial difficulties. To combat the challenges, Kenya instituted user fees, which reduced attendance at government health facilities by 40-50%, especially for the poor. In response to this, District Health Organizations waived fees for the poor and children under the age of 5. Unfortunately, difficulty in identifying the poor and lack of systematic methods to reach informal workers blocked outreach to these groups and inclusion in the program for the vulnerable.
In 1993 the MOH began working on a health reform plan employing decentralization as a guiding strategy. In 1994 the Kenya Health Policy Framework Paper (KHPFP) was published, aiming for “quality health care that is acceptable, affordable, and accessible to all” by 2010. The KHPFP was implemented through 2 five-year National Health Sector Strategic Plans (NHSSP), which worked to decentralize the health system by assigning more management activities to district level organizations and organizing a Sector Wide Approach (SWap) that brings together all stakeholders (the government, donors, NGOs) under a single budget, monitoring system, and coordinating function. The NHSSP also implemented the Kenya Essential Package for Health (KEPH), which shifted the health focus from vertical disease-specific to an emphasis on 6 stages of the human life cycle (cohorts).
NHIF exists alongside the private health insurance sector. While only about 2% of the population is covered by the private insurance market, the sector is still one of the most developed and dynamic in Sub-Saharan Africa.. Private insurers generally focus more on middle and high income groups, providing health insurance at premiums that are related to risk.
In an attempt to create a health insurance network with wider and more equitable coverage, in 2004 the National Social Health Insurance Fund (NSHIF) was proposed to achieve universal health coverage by imposing a social tax on the employed to subsidize health insurance for those who cannot pay. NSHIF was passed by Parliament in 2004, but due to a number of protests and questions about the structure, financing model and from both the private sector and the civil society the President returned it for debate and it was subsequently not passed. As a response, a 10/20 policy was implemented to lower outpatient expenses, involving a payment system through which primary health care provided at dispensaries and health centers is free for all citizens, except for a minimum registration fee of Kenya Shillings (KES) 10 at dispensaries and 20 at health centers (approximately USD 0.2 and 0.3). Unfortunately, payments are still required for the majority of services, even vulnerable groups, essentially negating the social justice aspect.
The National Hospital Insurance Fund (NHIF) is the primary provider of health insurance in Kenya with a mandate to enable all Kenyans to access quality and affordable health services. NHIF was restructured by the repeal of the National Hospital Insurance Act (CAP 255) and the enactment of the National Hospital Insurance Fund Act No. 9 in 1998. This new law made the NHIF an autonomous parastatal, separating it from the direct control of the Ministry of Health.
The National Hospital Insurance Fund (NHIF) is the primary provider of health insurance in Kenya with a mandate to enable all Kenyans to access quality and affordable health services. NHIF was restructured by the repeal of the National Hospital Insurance Act (CAP 255) and the enactment of the National Hospital Insurance Fund Act No. 9 in 1998. This new law made the NHIF an autonomous parastatal, separating it from the direct control of the Ministry of Health. The Fund is governed by a Board of Directors with representatives from civil society, employers, and local governments. The Health Insurance Act of 1998 makes no distinction between formal and informal sector, and indicates that membership shall be mandatory for all Kenyans at least 18 years of age. In practice, however, while Kenya has achieved high levels of coverage of the formal sector, coverage of the informal sector has proved more challenging.
Contributions are calculated on a graduated scale based on income, with a majority contributing between KES 30 to KES 320 per month. For the self-employed and others in the informal sector, membership is contributory and is available for a fixed premium of 160 KES per month. All Kenyans are eligible for membership if they are at least 18 years of age. In total, NHIF has about 2.7 million contributors and 6 million dependents, or about 1/5 of the total population.
Kenya
Summary of Reforms
The National Hospital Insurance Fund (NHIF) is the primary provider of health insurance in Kenya with a mandate to enable all Kenyans to access quality and affordable health services. NHIF was restructured by the repeal of the National Hospital Insurance Act (CAP 255) and the enactment of the National Hospital Insurance Fund Act No. 9 in 1998. This new law made the NHIF an autonomous parastatal, separating it from the direct control of the Ministry of Health. The Fund is governed by a Board of Directors with representatives from civil society, employers, and local governments. The Health Insurance Act of 1998 makes no distinction between formal and informal sector, and indicates that membership shall be mandatory for all Kenyans at least 18 years of age. In practice, however, while Kenya has achieved high levels of coverage of the formal sector, coverage of the informal sector has proved more challenging.
Contributions are calculated on a graduated scale based on income, with a majority contributing between KES 30 to KES 320 per month. For the self-employed and others in the informal sector, membership is contributory and is available for a fixed premium of 160 KES per month. All Kenyans are eligible for membership if they are at least 18 years of age. In total, NHIF has about 2.7 million contributors and 6 million dependents, or about 1/5 of the total population.
In addition, the 2005/2006 Kenya National Health Accounts (KNHA) note the top two “key challenges to achieving better health status in Kenya” as “inequitable access to health services,” and “shortages of qualified health workers with appropriate skills.” Kenya still has difficulties financing the health system. The government only spends about 5% of its total spending on healthcare, or approximately USD $11.80 per capita, well below the WHO recommended spending level of USD $34 per capita.
In addition, the 2005/2006 Kenya National Health Accounts (KNHA) note the top two “key challenges to achieving better health status in Kenya” as “inequitable access to health services,” and “shortages of qualified health workers with appropriate skills.” Kenya still has difficulties financing the health system. The government only spends about 5% of its total spending on healthcare, or approximately USD $11.80 per capita, well below the WHO recommended spending level of USD $34 per capita. Tax revenues have proven to be an unreliable source of health finance. This is true for a number of reasons, including macroeconomic conditions such as poor growth, national debt, and inflation, but primarily due to the small number of people in the formal sector who are taxed in Kenya. As a result, the health system is heavily dependent on donor sources and private out-of-pocket expenditures. In 2008, the public sector (composed of the Ministry of Health, local governments, and parastatals such as the National Hospital Insurance Fund) only provided 29% of total health expenditure (THE), while 31% came from donors and 36% came from private household expenditures, and mainly through out of pocket spending. While this is still lower than many other regional countries where external funds account for 30-40% of THE, the under-financing of the health sector has reduced its ability to ensure an adequate level of healthcare for the population. In addition, the high level of out of pocket expenditures pose a serious barrier to a majority of Kenyans; among those Kenyans who are ill and do not choose to seek care, 44% were hindered by cost. In addition, the 10/20 program had a number of problems including declining revenue as a result of inadequate compensation of facilities for revenue loss; lack of knowledge by health personnel about the policy; lack of knowledge among the health services users; lack of comprehensive reform measures to address issues of increase in numbers of those seeking care resulting from reduction of user fees; inadequate human resources and equipment; and drug shortages
In addition, the 2005/2006 Kenya National Health Accounts (KNHA) note the top two “key challenges to achieving better health status in Kenya” as “inequitable access to health services,” and “shortages of qualified health workers with appropriate skills.” Individuals in rural areas generally only have access to local level facilities, and frequently must travel up to 15 kilometers to reach any services. Human and physical resources are also unevenly distributed between urban and rural environments, and between public and private facilities. Doctors and support staff were found to be overstaffed at district and provincial level hospitals and acutely understaffed at a majority of health centers and dispensaries. According to 2008 figures, there were only 728 medical doctors working in the Kenyan health system, with only 477 employed in the public sector. With little incentive provided, well-qualified health workers rarely choose to work in rural health facilities, resulting in chronic human resource shortages, in terms of both the number and qualifications of health workers. This inequality will need to be addressed in order to ensure that all Kenyans are able to effectively take advantage of health insurance and health care.
While Vision 2030 and the health plans that preceded it focused on decentralization, the system has not yet become unified. There is still very little coordination between the private sector, the national level, and local levels. The MOH is unable to provide the district levels with timely resources, information sharing between the sectors is lacking, and there is no national system for monitoring health care. There is also a great deal of politicization, duplication of services, competition for resources, and weak management, which hinders the realization of a uniform system and the decentralization strategy. In order to fix these problems, a more coherent and unified system must be created, through which the government can monitor and delegate authority to and resources to local levels.
Kenya
The Way Forward
In addition, the 2005/2006 Kenya National Health Accounts (KNHA) note the top two “key challenges to achieving better health status in Kenya” as “inequitable access to health services,” and “shortages of qualified health workers with appropriate skills.” Kenya still has difficulties financing the health system. The government only spends about 5% of its total spending on healthcare, or approximately USD $11.80 per capita, well below the WHO recommended spending level of USD $34 per capita. Tax revenues have proven to be an unreliable source of health finance. This is true for a number of reasons, including macroeconomic conditions such as poor growth, national debt, and inflation, but primarily due to the small number of people in the formal sector who are taxed in Kenya. As a result, the health system is heavily dependent on donor sources and private out-of-pocket expenditures. In 2008, the public sector (composed of the Ministry of Health, local governments, and parastatals such as the National Hospital Insurance Fund) only provided 29% of total health expenditure (THE), while 31% came from donors and 36% came from private household expenditures, and mainly through out of pocket spending. While this is still lower than many other regional countries where external funds account for 30-40% of THE, the under-financing of the health sector has reduced its ability to ensure an adequate level of healthcare for the population. In addition, the high level of out of pocket expenditures pose a serious barrier to a majority of Kenyans; among those Kenyans who are ill and do not choose to seek care, 44% were hindered by cost. In addition, the 10/20 program had a number of problems including declining revenue as a result of inadequate compensation of facilities for revenue loss; lack of knowledge by health personnel about the policy; lack of knowledge among the health services users; lack of comprehensive reform measures to address issues of increase in numbers of those seeking care resulting from reduction of user fees; inadequate human resources and equipment; and drug shortages
In addition, the 2005/2006 Kenya National Health Accounts (KNHA) note the top two “key challenges to achieving better health status in Kenya” as “inequitable access to health services,” and “shortages of qualified health workers with appropriate skills.” Individuals in rural areas generally only have access to local level facilities, and frequently must travel up to 15 kilometers to reach any services. Human and physical resources are also unevenly distributed between urban and rural environments, and between public and private facilities. Doctors and support staff were found to be overstaffed at district and provincial level hospitals and acutely understaffed at a majority of health centers and dispensaries. According to 2008 figures, there were only 728 medical doctors working in the Kenyan health system, with only 477 employed in the public sector. With little incentive provided, well-qualified health workers rarely choose to work in rural health facilities, resulting in chronic human resource shortages, in terms of both the number and qualifications of health workers. This inequality will need to be addressed in order to ensure that all Kenyans are able to effectively take advantage of health insurance and health care.
While Vision 2030 and the health plans that preceded it focused on decentralization, the system has not yet become unified. There is still very little coordination between the private sector, the national level, and local levels. The MOH is unable to provide the district levels with timely resources, information sharing between the sectors is lacking, and there is no national system for monitoring health care. There is also a great deal of politicization, duplication of services, competition for resources, and weak management, which hinders the realization of a uniform system and the decentralization strategy. In order to fix these problems, a more coherent and unified system must be created, through which the government can monitor and delegate authority to and resources to local levels.
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