New health insurance scheme: The devil is in the guidelines

The Kenyan Constitution 2010 provides under 43 (1, a) that every person has the right to the highest attainable standard of health, which includes the right to healthcare services, including reproductive health care; Article 43 (2) also recognises that a person shall not be denied emergency medical treatment. It recognises the government as a duty holder responsible for ensuring health services do not expose the citizens to financial hardships.

Indeed, one of the most critical challenges faced by Kenyan health systems is the generation of a sustainable financing mechanisms capable of delivering universal health coverage for her people as most informal sector workers representing 83.3 percent of the total workforce and have no health insurance, exposing entire families to impoverishment and risk of reversing progress made in achieving health outcomes in the country.

Kenya, despite the hurdles, is committed to achieving universal health coverage with the current government making strides to its realisation by passing four of the Universal Health Coverage laws including the Social Health Insurance Fund (SHIF), Facility Improvement Financing, Digital Health and Primary Health Care. This proposed shift comes at a time when reliance on donor funding has declined given the county elevation to a low-middle income country and poses a risk on progress made in achieving the SDG Goal 3 focusing on reducing maternal, newborn and child mortality and in achieving the Kenya 2016 RMNCAH investment framework which focuses on strategies to address these major bottlenecks and gaps.

Regulations

The recent reforms and regulatory frameworks set forth in the Social Health Insurance (General) Regulations, 2023 are designed to enhance healthcare accessibility, affordability, and quality. An analysis by Pathways Policy Institute suggests that the 2.75 percent deductions from employed Kenyans through the SHIF could potentially double the total contributions from Sh60 billion collected by National Health Insurance Fund (NHIF) annually to Sh125 billion, such an increment brings significant implications for Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH) in Kenya as the legislation also aims to enhance their access and quality to health, focusing on the specific needs of vulnerable groups such as women, children, and adolescents. Importantly, specific services such as antiretrovirals (ARVs), HIV testing, family planning, anti-malaria, and vaccinations are provided at no cost to the patient.

Under the Primary Healthcare Fund, outpatient care services that are accessible at Level 2, 3, and 4 primary healthcare referral facilities. The Primary Healthcare fund, however, will only be disbursed at the end of each quarter meaning the facilities have to foot their initial bills; if not Kenyans will dip into their pockets.

Maternity services are robust, covering antenatal care, delivery and aftercare. However, there is a disclaimer that incase of peripartum and postnatal complications, then per diem rates take effects and claims will have to undergo surveillance before being granted. It also indicates that management of complications for the newborn and mother will be charged separately.

Financial Protection and Accessibility

Financial protection and accessibility are also key features of the Act. It aims to reduce the financial burden on families seeking RMNCAH services by providing a structured financing mechanism through the Social Health Insurance Fund and the Primary Healthcare Fund.

Impact on maternal, reproductive and child health outcomes

While the Act and guidelines comprehensive coverage and quality assurance measures are expected to significantly improve maternal and child health outcomes, the costs and guidelines are leading citizens to worry about full access and choice.

Mr Ngure is the Founder Pathways Policy Institute