Road to UHC: The makings of a Benefits Package


Kenyans and those residing in Kenya would be required to part with a certain amount of their income as a contribution to the Social Health Insurance Fund.

Photo credit: File

For many years, Kenyans have thought of the repealed National Hospital Insurance Fund (NHIF) as primarily a payer of healthcare services.

In its infancy years, NHIF would pay for a patient’s hospital bed which later evolved to paying for hospital stays including procedures and treatment.

Eventually, there were packages covering services from dialysis to chemotherapy.

Therefore, for the contribution you made to NHIF you would receive certain benefits. The legal reforms guiding Kenya’s road to Universal Health Coverage (UHC) called for revising the existing Benefits Package (BP).

Put simply, UHC promises health coverage for all. BP defines what the government can deliver and what the citizens can demand subject to budget realisation.

The Politics behind the road to Universal Health Coverage

However, the development of the health benefits package is both a technical and political process to identify services, interventions, and priority commodities. If all three funds under the Social Health Authority were tax-funded with no contributions necessary, the discourse would have primarily focused on budget allocations and ring-fencing certain taxes for healthcare.

Strategic Purchasing

However, Kenyans and those residing in Kenya would be required to part with a certain amount of their income as a contribution to the Social Health Insurance Fund (Shif), there are deliberations around what services households would access, whether would they still have to dip into their pockets to pay for care and is it UHC?

Hence the need for the health benefits package to be explicit, that is with a clear list of health services that are available for beneficiaries which could be reviewed periodically. This requires strategic purchasing frameworks.

Kenya’s strategic purchasing approach means deliberately directing health funds to priority populations, interventions, and services, and actively creating incentives so funds are used by providers equitably and in alignment with a population’s health needs.

The relationship between providers, purchasers and payers is much more complex than an exchange of cash for services.


SPECIAL EDITION: SHIF and questioning the proposed benefits package

To understand this dynamic relationship, we must recognize the key strategic health purchasing factors. They include who the purchaser (Social Health Authority); What to purchase; who to purchase from (contracting providers based on a range of services and locations with a mix of public, private or faith-based facilities); how to purchase (mechanisms through which payment will be made to providers) and for whom purchases will be made (populations to be covered).

Provider Payment Mechanisms

The challenge lies in how to pay providers to align their interests with those of the patients and the purchaser. The way providers are paid to deliver the covered package of services may ultimately make it possible to expand coverage within limited funds.

That is, they can help balance system revenues and costs and create incentives for providers to improve quality and deliver services more efficiently. This is no easy task.

Many countries use a mix of payment methods ranging from line-item budgets (providers receive a fixed amount to cover specific input expenses such as personnel) to capitation (providers are paid a fixed amount in advance to provide a defined set of services for everyone enrolled for a fixed period).

The design of the payment systems and appropriate payment rates is based on a combination of policy priorities, cost information and negotiations. The assumption is always made that certain facilities will opt for a specific contract, and this will impact where you can receive services and if you will pay out of pocket.

Performance Monitoring

It remains to be seen if we have robust implementation arrangements and supporting systems with clear contracts, communication, information systems, complementary measures and what will be used for performance monitoring.

The draft benefit package presented during stakeholder engagement covers a wide range of services: The expected inpatient, outpatient, surgical, dialysis, maternity, oral and optical; The expounded oncology, radiology, and screening; and the long overdue assisted devices, mental health, accident, and emergency services benefits packages.

We are unable to discuss the exact rates/tariffs that would be paid to providers and specific benefits to households in its draft form. Once approved, Kenyans and residents should familiarize themselves with the benefits package. Although catastrophic healthcare expenditure is not necessarily a thing of the past, we are making great strides on this road to UHC.

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Dr Wangari is a medical doctor; [email protected]