Avoid NHIF mistakes in the new health insurance policy

The National Health Insurance Fund (NHIF) has had a detrimental role in obstructing progress within the healthcare sector.

NHIF’s policies, particularly regarding accreditation and reimbursement, have stifled innovation and perpetuated inequalities, ultimately hindering our efforts to provide quality care to all.

The proposed Social Health Authority (SHA) should note NHIF’s shortcomings to prevent a recurrence.

A most glaring issue was NHIF’s insistence on accrediting hospitals based solely on their level designation rather than specialised capabilities.

The outdated approach has led to the failure to develop centres of excellence focused on specific areas of healthcare.

For example, requiring Level 4 hospitals to have maternity wings discouraged the development of centres specialised in, say, orthopaedics. 

Also, limiting chemotherapy to Level 4 hospitals discouraged the establishment of standalone infusion centres, specialised in critical treatments like chemotherapy and blood transfusions.

The rigidity not only contradicts global healthcare trends but also restricts access to specialised services for patients.

Enhance overall healthcare quality

NHIF’s basing approval process for procedures solely on the registration of a clinician by the Kenya Medical Practitioners and Dentists Board (KMPDB) has led to medical procedures being performed by unskilled or unspecialised people, often with adverse outcomes.

Its insistence that Level 3B daycare facilities, introduced by KMPDB to register specialist centres, have a laboratory discourages the growth of high-quality, high-volume labs.

That favours smaller, less efficient labs that struggle with quality standards and come with huge costs.

The same goes for pharmaceutical services. Models like those in Japan and the UK, where pharmacies are separate from hospitals, promote specialized pharmaceutical services and enhance overall healthcare quality.

What is wrong with a dialysis centre partnering with an accredited lab and an accredited pharmacy? Why must we have a lab for someone performing an outpatient procedure, in some countries is done in private residences?

It is disconcerting to learn that the Health ministry is mulling recategorising health facilities as a prerequisite to implement the Social Health Insurance Fund (Shif) — a futile endeavour.

Accredit approved services in facilities based on the availability of all required components. For example, a Level 4 facility with an operating theatre may be accredited to offer hysterectomy if it has a gynaecologist.

Align with patients’ needs

With primary healthcare top of the agenda, NHIF’s reimbursement policies exacerbate disparities in healthcare access by favouring higher-level facilities over lower-level ones.

By offering higher reimbursements for deliveries in higher-level facilities, NHIF inadvertently incentivises the concentration of resources and services in these institutions, neglecting the development of primary healthcare facilities.

This approach not only limits access to essential services for underserved communities but also impedes the overall growth of our healthcare system.

Reverse referral further underscores these shortcomings. In regions with a high prevalence of specific diseases such as sickle cell anaemia, establishing outpatient facilities in lower-level hospitals could significantly improve access to care.

For example, where there is a high prevalence of sickle cell anemia, shouldn’t a Level 3 hospital with a regular visiting paediatrician and lab cater to them?

SHA must reassess these policies to better align with patients’ needs and the realities of our healthcare system. We require a more flexible approach that rewards quality of care and fosters innovation.

SHA should incentivise collaboration between levels of care and also facilities to ensure equitable access to quality healthcare services for all Kenyans.

Dr Ganda, an obstetrician, gynaecologist and gynaecologic oncologist, is the County Executive Committee Member for Health and Sanitation in the Kisumu County Government. [email protected]