Kenyans should embrace change to social health

Social health insurance (SHI) is a form of health financing mechanism successfully implemented in many developed countries that has contributed to achievement of universal health coverage (UHC) and equity. Social health has also been implemented in numerous developing countries, including, Kenya to achieve UHC. 

Many Kenyans, I suppose, are wondering why the Social Health Authority (SHA) was established to replace the National Health Insurance Fund (NHIF). Over the last 66 years, NHIF has touched the lives of many and increased access to health services.

However, it was designed for those in formal employment — 20 per cent of the population. This leaves out 80 per cent of Kenyans in the informal sector, who are actively participating in economic activities and generating revenue.

SHI has the potential to revolutionise healthcare access in Kenya. Its success hinges on its three key advantages. First, in keeping with the principle of UHC, SHI is mandatory for all Kenyans, ensuring a wider pool of contributors.

Currently, contributions are mandatory for the formal sector and voluntary for the informal sector. This can lead to “adverse selection”, where only those needing immediate care enrol, placing financial strain on the system and making it unsustainable.

To address this, all Kenyans are encouraged to register for SHI by dialling *147# or visiting the SHA website (www.sha.go.ke). Widespread participation is crucial for long-term sustainability. 

Secondly, SHI operates by pooling resources through regular premiums. These premiums shall be deducted from salaries for formal sector employees or paid directly by individuals in the informal sector. This collective contribution ensures a more balanced pool of participants, mitigating financial risk and ensuring financial sustainability. 

Lastly, a clearly defined benefits package is key. The Ministry of Health has developed a clear list of services covered through a transparent process. By registering, Kenyans gain access to this defined benefits package, allowing us to utilise healthcare services for ourselves and our dependants.

Community health services

Increased registration translates to a larger pool of contributors and ensures efficient use of resources. The national validation of the tariffs to the benefits package was carried out last week and it included stakeholder engagement and public participation. The benefits package has since been gazetted. 

SHA, unlike NHIF, will oversee these schemes instead of one. The Social Health Insurance Act (SHIA) of 2023 introduces three funds: the government-funded Primary Healthcare Fund (PHCF), the contributory Social Health Insurance Fund (SHIF), and the government-funded Emergency, Chronic, and Critical Illness Fund (ECCIF). 

The prerequisite to access the SHIF is to be a paid up member of SHA. In addition, there is a purposeful shift from the costly curative services to preventive care, with emphasis on community health services at the individual and household level. This shift is evident in the SHA benefits package, which includes targeted screening for the top four cancers—breast, cervix, prostate and colon—management of precancerous lesions and provision of palliative care services along the continuum of care. 

Under NHIF, the renal package traditionally offered two sessions of dialysis at a cost of Sh9,500 per session. This has been increased to Sh11,650 per session and an additional third session of dialysis can be accessed without co-payment upon assessment and recommendation by a kidney specialist.

Further, in the new SHA benefit package before a sick member goes for a kidney transplant, the tests and evaluations for the donor and the recipient will be catered for at Sh150,000. SHA will also cater for the removal of the donor kidney at cost of Sh168,000.

The total payment for kidney transplant has been increased from Sh500,000 to Sh700,000. Progressively, this will be improved to cover other transplants such as bone marrow and liver. Unlike NHIF that had a limited cover for patients with chronic conditions, the SHA outpatient benefits package will cover laboratory investigations for chronic conditions.

While Kenya has made significant strides in improving maternal and child health, challenges persist, particularly in rural and marginalised areas. Finance remains a significant barrier to maternal health outcomes. Linda Mama, established in 2013, was introduced to address this challenge.

Under the SHI benefits package, the programme, now renamed Maternity, Newborn and Child Services, has been expanded. Antenatal care visits now include essential services like Anti-D serum for Rh-negative mothers and one ultrasound, as recommended by the Ministry of Health. Postnatal care has also been extended to six visits from the previous two. The enhanced package covers all complications related to pregnancy, delivery and newborn care, either under inpatient services or critical care. 

Equitable healthcare system

SHA has also significantly increased reimbursement rates for maternity services. Normal deliveries are now reimbursed at Sh10,000, while C-section deliveries are reimbursed at Sh30,000 across all health facilities. These increased rates will help healthcare providers to deliver high-quality care.

It is important to note that students are now covered under their parents’ SHI benefits. Parents are encouraged to register their children to ensure they have access to these enhanced health care services.

SHI will offer a more equitable healthcare system. It will promote cross-subsidisation, where younger, healthier individuals contribute to the plan, benefiting older or less healthy people. Similarly, those with higher incomes help finance healthcare for those who are less fortunate. SHI boasts a leaner governance structure, capping operational expenses at 5 per cent compared to the previous 15 per cent. This translates to more resources available for purchase of healthcare services.

The SHI Act and regulations aim to significantly increase the number of registered Kenyans, expanding access to quality healthcare services nationwide. This includes reduced human interaction through digitised processes, such as automated pre-authorisation for treatment.

However, challenges remain. Sub-optimal digital connectivity in some facilities, particularly at level 2 and 3, could hinder smooth implementation. 

Additionally, infrastructure limitations in dispensaries and health centres require addressing to meet the anticipated surge in patient numbers. Another potential hurdle is the existing human resource gap. The influx of new registrations could lead to delays in service provision or longer waiting times if this issue is not addressed.

Finally, outstanding debts owed by NHIF to healthcare providers pose a risk to a smooth transition. The Ministry is actively working with the National Treasury to ensure these debts are settled.

By addressing the identified risks and ensuring a smooth transition, SHI holds the potential to transform healthcare access in the country.

Dr Amoth is the Director-General for Health and former Chair of the Executive Board of the World Health Organization.