Confusion between the National Health Insurance Fund (NHIF) and private hospitals has led to critically ill patients being denied treatment, Nation has learnt.
Fearing reprisals, most of the hospital managers who spoke to Nation requested anonymity because the system may end up not paying their claims.
They said patients, especially those with chronic illnesses, have been turned away from hospitals. Most of them depend on NHIF for their treatment.
Hospitals have declared that patients with NHIF cards will not be served until further notice and until they receive a substantial amount of money from the government agency.
Hospital managers said NHIF owes them Sh12 million, a figure that has been accumulating since last year. Some of the hospitals affected are those that have signed a comprehensive cover agreement with the fund, allowing patients to receive treatment without paying a single cent to the healthcare provider.
However, with non-comprehensive cover, facilities charge patients whatever they want, but the reimbursement is standardised across all facilities. Facilities were free to choose what worked for them. The idea was for the government to invest money in public hospitals, where, officials argued, the majority of Kenyans go for services.
"We have had patients receiving dialysis at our facilities since the middle of last year and, together with other treatments using NHIF cover, claims have accumulated to almost Sh9 million. We received the first batch of payments last week and they are paying in bits and pieces," the manager told Nation.
He added: "If you owe me almost Sh10 million and you are paying me Sh1 million, how do you honestly expect me to run the day-to-day finances of the hospital, including the purchase of consumables? It cannot work. Let me wait for them to pay me for the services I have already rendered to Kenyans before I start accumulating more," the manager said.
A public referral hospital said it had accumulated a number of unpaid bills amid rising concern this was negatively affecting its operations.
"In a day we see close to over 1,000 patients and 90 per cent of the patients use NHIF cards to access services, most of the patients do not have private insurance. If the situation continues, we will have no option but to stop attending to patients,” he said.
An insider told Nation NHIF is broke and the National Treasury owes it over Sh27 billion. He further pointed out that counties are not remitting money to the NHIF, making it difficult for the fund to have money to pay hospitals.
"It is from counties’ statutory deductions that NHIF gets its money and what the government has done — insuring the National Police Service, Kenya Prison Service, Teachers Service Commission through private firms — has confused the fund," the source said.
According to a letter from the Inspector-General of Police to the NHIF boss dated December 16, 2022, the fund has failed to provide medical services to officers.
"We regret to inform you that your bid was not successful because it was not the lowest technically responsive bid in the financial evaluation. You quoted Sh9.4 billion," the letter said.
The contract was awarded to CIC General and a consortium of other firms at a total annual premium of Sh8. 7 billion.
"This has really affected the cash flow of the fund as the two cadres alone would have earned the fund close to Sh70 billion and as it is now, the fund is broke with no money to pay facilities," said the insider.
He expressed fears that, if the situation holds for the next two months, the entire health sector will be affected as most hospitals, both public and private, depend on the fund.
"The government should pay what it owes if it really wants to save the health sector," he said.
Dr Davji Atella, the secretary-general of the Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU), said many hospitals were suffering because the government was out to frustrate and withdraw funding from the NHIF.
"The government cannot pretend to increase NHIF funds by increasing deductions from workers by up to 2.75 per cent of gross salaries when the same government has been on a spree of defunding NHIF," Dr Atella said.
He alleged that both the national and county governments have been diverting over Sh20 billion annually from NHIF to private insurance companies that are making money instead of giving the tenders to the national health insurer.
"Civil servants, including the police and the Parliamentary Service Commission, State officials and all county governments have private insurance, how do you expect NHIF to stand on its own? This whole mess is caused by the government," he said.
Last week, private hospitals appealed to NHIF to release payments to enable them to serve their clients.
Kenya Association of Private Hospitals secretary-general Timothy Olweny said the situation was unsustainable for most hospitals and the only way to save them was to release payments.
"Most hospitals are in debt and the only way they can continue to provide quality healthcare to their clients and NHIF members is if the money is released," he said.
"If patients come, get services and leave without paying a single cent, then they [private hospitals]have to wait for a long time for the money to be reimbursed. How are they going to operate? There needs to be a serious discussion now," he said.
Attempts to reach the NHIF acting chief executive officer, Mr Samson Kuhora, were futile as calls and messages went unanswered. Dr Kuhora was appointed on March 14, taking over from Dr Peter Kamunyo whose term ended in April.